FHIR Implementation Guide for ABDM
6.5.0 - active
This page is part of the FHIR Implementation Guide for ABDM (v6.5.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DiagnosticReportRecord | Version: 6.5.0 | |||
Draft as of 2020-08-31 | Computable Name: DiagnosticReportRecord |
The Clinical Artifact represents diagnostic reports including Radiology and Laboratory reports that can be shared across the health ecosystem.
This profile sets minimum expectations for the DiagnosticReportRecord that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation to a Diagnostic Report of a patient. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.
The resources capturing the measurements, tests, panels, observations, interpretation, etc. in Diagnostics domain can use LOINC codes. The guide for using the LOINC codes in the FHIR resources can be found here.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
Name | Flags | Card. | Type | Description & Constraints![]() |
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0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
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?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
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?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
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?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://snomed.info/sct |
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Σ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children |
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SΣ | 0..1 | string | Plain text representation of the concept ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
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Σ | 0..1 | Reference(Encounter) | Context of the Composition ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
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SΣ | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children |
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S | 0..* | BackboneElement | Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |
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0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition ele-1: All FHIR elements must have a @value or children | |
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Σ | 0..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children |
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SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
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0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children | |
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SΣ | 0..* | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://snomed.info/sct |
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Σ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children |
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Σ | 1..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children |
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SΣ | 0..1 | string | Plain text representation of the concept ele-1: All FHIR elements must have a @value or children |
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0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section ele-1: All FHIR elements must have a @value or children | |
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SC | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type ele-1: All FHIR elements must have a @value or children |
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C | 0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. ele-1: All FHIR elements must have a @value or children |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
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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). ele-1: All FHIR elements must have a @value or children Fixed Value: DiagnosticReport |
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C | 0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport ele-1: All FHIR elements must have a @value or children |
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
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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). ele-1: All FHIR elements must have a @value or children Fixed Value: DocumentReference |
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Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.entry:DiagnosticReport.type | extensible | Fixed Value: DiagnosticReporthttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | |
Composition.section.entry:DocumentReference.type | extensible | Fixed Value: DocumentReferencehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard |
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() |
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints![]() |
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0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. | |
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S | 1..1 | code | preliminary | final | amended | entered-in-error |
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S | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) |
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1..1 | Coding | Code defined by a terminology system | |
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1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
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1..1 | code | Symbol in syntax defined by the system | |
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1..1 | string | Representation defined by the system | |
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S | 0..1 | string | Plain text representation of the concept |
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S | 1..1 | Reference(Patient) | Who and/or what the composition is about |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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0..1 | Reference(Encounter) | Context of the Composition | |
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S | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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S | 0..* | BackboneElement | Attests to accuracy of composition |
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0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition | |
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0..1 | Reference(Organization) | Organization which maintains the composition | |
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S | 1..1 | BackboneElement | Composition is broken into sections |
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S | 0..* | Coding | Code defined by a terminology system |
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1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
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1..1 | code | Symbol in syntax defined by the system | |
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1..1 | string | Representation defined by the system | |
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S | 0..1 | string | Plain text representation of the concept |
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0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section | |
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S | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
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0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. | |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: DiagnosticReport | |
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0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport | |
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1..1 | string | Literal reference, Relative, internal or absolute URL | |
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1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: DocumentReference | |
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Path | Conformance | ValueSet | URI |
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG |
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
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0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. | |||||
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Σ | 0..1 | id | Logical id of this artifact | ||||
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Σ | 0..1 | Meta | Metadata about the resource | ||||
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?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
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0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
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0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
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0..* | Resource | Contained, inline Resources | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?! | 0..* | Extension | Extensions that cannot be ignored | ||||
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Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
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?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
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SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
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Σ | 1..1 | string | Representation defined by the system | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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SΣ | 0..1 | string | Plain text representation of the concept | ||||
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Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
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SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
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Σ | 1..1 | dateTime | Composition editing time | ||||
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SΣ | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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). | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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Σ | 1..1 | string | Human Readable name/title | ||||
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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. | ||||
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S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
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0..1 | dateTime | When the composition was attested | |||||
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0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition | |||||
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Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
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0..* | BackboneElement | Relationships to other compositions/documents | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
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1..1 | Target of the relationship | ||||||
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Identifier | |||||||
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Reference(Composition) | |||||||
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Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
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Σ | 0..1 | Period | The period covered by the documentation | ||||
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Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
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SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Label for section (e.g. for ToC) | |||||
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0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 0..* | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
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Σ | 1..1 | string | Representation defined by the system | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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SΣ | 0..1 | string | Plain text representation of the concept | ||||
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0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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SC | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type | ||||
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C | 0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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: DiagnosticReport | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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C | 0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
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: DocumentReference | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() ![]() |
C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
![]() ![]() ![]() ![]() |
C | 0..* | See section (Composition) | Nested Section | ||||
![]() |
Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.entry:DiagnosticReport.type | extensible | Fixed Value: DiagnosticReporthttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.entry:DocumentReference.type | extensible | Fixed Value: DocumentReferencehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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() |
This structure is derived from Composition
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management | |
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
![]() ![]() ![]() |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
Σ | 1..1 | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://snomed.info/sct |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Plain text representation of the concept ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Context of the Composition ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
Σ | 1..1 | dateTime | Composition editing time ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
Σ | 1..1 | string | Human Readable name/title ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
S | 0..* | BackboneElement | Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
![]() ![]() ![]() ![]() |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() ![]() |
0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() |
SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both |
![]() ![]() ![]() ![]() |
0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..* | Coding | Code defined by a terminology system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | uri | Identity of the terminology system ele-1: All FHIR elements must have a @value or children Fixed Value: http://snomed.info/sct |
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | code | Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Representation defined by the system ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Plain text representation of the concept ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() |
0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section ele-1: All FHIR elements must have a @value or children | |
![]() ![]() ![]() ![]() |
SC | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
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). ele-1: All FHIR elements must have a @value or children Fixed Value: DiagnosticReport |
![]() ![]() ![]() ![]() ![]() |
C | 0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children |
![]() ![]() ![]() ![]() ![]() ![]() |
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). ele-1: All FHIR elements must have a @value or children Fixed Value: DocumentReference |
![]() |
Path | Conformance | ValueSet / Code | URI |
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG | |
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | |
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | |
Composition.section.entry:DiagnosticReport.type | extensible | Fixed Value: DiagnosticReporthttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | |
Composition.section.entry:DocumentReference.type | extensible | Fixed Value: DocumentReferencehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard |
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() |
Differential View
This structure is derived from Composition
Name | Flags | Card. | Type | Description & Constraints![]() |
---|---|---|---|---|
![]() ![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. | |
![]() ![]() ![]() |
S | 1..1 | code | preliminary | final | amended | entered-in-error |
![]() ![]() ![]() |
S | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) |
![]() ![]() ![]() ![]() |
1..1 | Coding | Code defined by a terminology system | |
![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system | |
![]() ![]() ![]() ![]() ![]() |
1..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() |
S | 0..1 | string | Plain text representation of the concept |
![]() ![]() ![]() |
S | 1..1 | Reference(Patient) | Who and/or what the composition is about |
![]() ![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() ![]() |
0..1 | Reference(Encounter) | Context of the Composition | |
![]() ![]() ![]() |
S | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition |
![]() ![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() ![]() |
S | 0..* | BackboneElement | Attests to accuracy of composition |
![]() ![]() ![]() ![]() |
0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition | |
![]() ![]() ![]() |
0..1 | Reference(Organization) | Organization which maintains the composition | |
![]() ![]() ![]() |
S | 1..1 | BackboneElement | Composition is broken into sections |
![]() ![]() ![]() ![]() |
||||
![]() ![]() ![]() ![]() ![]() |
S | 0..* | Coding | Code defined by a terminology system |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | code | Symbol in syntax defined by the system | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | string | Representation defined by the system | |
![]() ![]() ![]() ![]() ![]() |
S | 0..1 | string | Plain text representation of the concept |
![]() ![]() ![]() ![]() |
0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section | |
![]() ![]() ![]() ![]() |
S | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: DiagnosticReport | |
![]() ![]() ![]() ![]() ![]() |
0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | string | Literal reference, Relative, internal or absolute URL | |
![]() ![]() ![]() ![]() ![]() ![]() |
1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: DocumentReference | |
![]() |
Path | Conformance | ValueSet | URI |
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints![]() | ||||
---|---|---|---|---|---|---|---|---|
![]() ![]() |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / a set of resources composed to define the diagnostic report record. | |||||
![]() ![]() ![]() |
Σ | 0..1 | id | Logical id of this artifact | ||||
![]() ![]() ![]() |
Σ | 0..1 | Meta | Metadata about the resource | ||||
![]() ![]() ![]() |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
![]() ![]() ![]() |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
![]() ![]() ![]() |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
![]() ![]() ![]() |
0..* | Resource | Contained, inline Resources | |||||
![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
![]() ![]() ![]() |
Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
![]() ![]() ![]() |
?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
![]() ![]() ![]() |
SΣ | 1..1 | CodeableConcept | Kind of composition (SNOMED CT if possible) Binding: Diagnostic Report Type (preferred) | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
Σ | 1..1 | Coding | Code defined by a terminology system | ||||
![]() ![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Version of the system - if relevant | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 1..1 | string | Representation defined by the system | ||||
![]() ![]() ![]() ![]() ![]() |
Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
![]() ![]() ![]() ![]() |
SΣ | 0..1 | string | Plain text representation of the concept | ||||
![]() ![]() ![]() |
Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
![]() ![]() ![]() |
SΣ | 1..1 | Reference(Patient) | Who and/or what the composition is about | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
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). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
![]() ![]() ![]() |
Σ | 1..1 | dateTime | Composition editing time | ||||
![]() ![]() ![]() |
SΣ | 1..* | Reference(Practitioner | PractitionerRole | Organization | Patient | Device | RelatedPerson) | Who and/or what authored the composition | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
![]() ![]() ![]() ![]() |
ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
![]() ![]() ![]() ![]() |
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). | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
![]() ![]() ![]() ![]() |
Σ | 0..1 | string | Text alternative for the resource | ||||
![]() ![]() ![]() |
Σ | 1..1 | string | Human Readable name/title | ||||
![]() ![]() ![]() |
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. | ||||
![]() ![]() ![]() |
S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
![]() ![]() ![]() ![]() |
0..1 | dateTime | When the composition was attested | |||||
![]() ![]() ![]() ![]() |
0..1 | Reference(Organization | Patient | Practitioner | PractitionerRole | RelatedPerson) | Who attested the composition | |||||
![]() ![]() ![]() |
Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
![]() ![]() ![]() |
0..* | BackboneElement | Relationships to other compositions/documents | |||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
![]() ![]() ![]() ![]() |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
![]() ![]() ![]() ![]() |
1..1 | Target of the relationship | ||||||
![]() ![]() ![]() ![]() ![]() |
Identifier | |||||||
![]() ![]() ![]() ![]() ![]() |
Reference(Composition) | |||||||
![]() ![]() ![]() |
Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
![]() ![]() ![]() ![]() |
0..1 | string | Unique id for inter-element referencing | |||||
![]() ![]() ![]() ![]() |
0..* | Extension | Additional content defined by implementations | |||||
![]() ![]() ![]() ![]() |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
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Σ | 0..1 | Period | The period covered by the documentation | ||||
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Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
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SC | 1..1 | BackboneElement | Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations | |||||
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?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
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0..1 | string | Label for section (e.g. for ToC) | |||||
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0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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SΣ | 0..* | Coding | Code defined by a terminology system | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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Σ | 1..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
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Σ | 0..1 | string | Version of the system - if relevant | ||||
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Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
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Σ | 1..1 | string | Representation defined by the system | ||||
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Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
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SΣ | 0..1 | string | Plain text representation of the concept | ||||
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0..* | Reference(Device | RelatedPerson | Patient | Practitioner | PractitionerRole | Organization) | Who and/or what authored the section | |||||
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0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
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C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
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0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
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0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
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SC | 1..2 | Reference(Resource) | A reference to data that supports this section Slice: Unordered, Closed by value:type | ||||
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C | 0..1 | Reference(DiagnosticReportLab | DiagnosticReportImaging) | The section records diagnostic reports which include both laboratory and imaging reports. These reports contain the results and interpretations of diagnostic tests performed on the patient. | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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: DiagnosticReport | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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C | 0..1 | Reference(DocumentReference) | The section records documents, such as PDFs or images, relevant to the DiagnosticReport | ||||
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0..1 | string | Unique id for inter-element referencing | |||||
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0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
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ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
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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: DocumentReference | ||||
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Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
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Σ | 0..1 | string | Text alternative for the resource | ||||
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C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
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C | 0..* | See section (Composition) | Nested Section | ||||
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Path | Conformance | ValueSet / Code | URI | |||
Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languages from the FHIR Standard
| ||||
Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
Composition.type | preferred | DiagnosticReportTypehttps://nrces.in/ndhm/fhir/r4/ValueSet/ndhm-diagnostic-report-type from this IG | ||||
Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
Composition.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification|2014-03-26 from the FHIR Standard | ||||
Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard | ||||
Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
Composition.event.code | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
Composition.section.code | example | DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard | ||||
Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard | ||||
Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-order from the FHIR Standard | ||||
Composition.section.entry:DiagnosticReport.type | extensible | Fixed Value: DiagnosticReporthttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.entry:DocumentReference.type | extensible | Fixed Value: DocumentReferencehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard |
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() |
This structure is derived from Composition
Summary
Mandatory: 9 elements(7 nested mandatory elements)
Must-Support: 10 elements
Fixed: 4 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron