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

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Resource Profile: HealthDocumentRecord

The Clinical Artifact represents the unstructured historical health records as a single of multiple Health Record Documents generally uploaded by the patients through the Health Locker and can be shared across the health ecosystem.

Usage:

• This Resource Profile is not used by any profiles in this Implementation Guide

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
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription 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
implicitRules	?!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
modifierExtension	?!	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
status	?!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
type	SΣ	1..1	CodeableConcept	Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children
coding	Σ	1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record ele-1: All FHIR elements must have a @value or children
system	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
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Record artifact
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition ele-1: All FHIR elements must have a @value or children
date	SΣ	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children
author	SΣ	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
title	SΣ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
attester	S	0..*	BackboneElement	Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children
modifierExtension	?!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
mode		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
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition ele-1: All FHIR elements must have a @value or children
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children
section	SC	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records. 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
modifierExtension	?!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
code		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
coding	SΣ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	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
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Record artifact
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section ele-1: All FHIR elements must have a @value or children
entry	SC	1..*	Reference(DocumentReference)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes 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()

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
status	S	1..1	code	preliminary | final | amended | entered-in-error
type	S	1..1	CodeableConcept	Kind of composition ("Prescription record ")
coding		1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display		1..1	string	Representation defined by the system Fixed Value: Record artifact
text	S	0..1	string	Plain text representation of the concept
subject	S	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about
reference		1..1	string	Literal reference, Relative, internal or absolute URL
encounter		0..1	Reference(Encounter)	Context of the Composition
date	S	1..1	dateTime	Composition editing time
author	S	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record
reference		1..1	string	Literal reference, Relative, internal or absolute URL
title	S	1..1	string	Human Readable name/title
attester	S	0..*	BackboneElement	Attests to accuracy of composition
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition
custodian		0..1	Reference(Organization)	Organization which maintains the composition
section	S	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records.
code
coding	S	0..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display		1..1	string	Representation defined by the system Fixed Value: Record artifact
text	S	0..1	string	Plain text representation of the concept
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section
entry	S	1..*	Reference(DocumentReference)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a 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
coding	Σ	1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record
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	1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Record artifact
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about
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	1..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	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Composition editing time
author	SΣ	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record
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	1..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	0..1	string	Text alternative for the resource
title	SΣ	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	S	0..*	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.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
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
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
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
code	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.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	SC	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records. 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
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		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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	SΣ	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	1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Record artifact
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(DocumentReference)	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	1..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	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
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	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.author.type	extensible	ResourceType 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	CompositionAttestationMode 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.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason 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()

This structure is derived from Composition

Summary

Mandatory: 10 elements(3 nested mandatory elements)
Must-Support: 12 elements
Fixed: 6 elements

Structures

This structure refers to these other structures:

• Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
• Encounter (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter)
• Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
• PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
• DocumentReference (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription 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
implicitRules	?!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
modifierExtension	?!	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
status	?!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
type	SΣ	1..1	CodeableConcept	Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. ele-1: All FHIR elements must have a @value or children
coding	Σ	1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record ele-1: All FHIR elements must have a @value or children
system	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
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Record artifact
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition ele-1: All FHIR elements must have a @value or children
date	SΣ	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children
author	SΣ	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
title	SΣ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
attester	S	0..*	BackboneElement	Attests to accuracy of composition ele-1: All FHIR elements must have a @value or children
modifierExtension	?!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
mode		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
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition ele-1: All FHIR elements must have a @value or children
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children
section	SC	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records. 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
modifierExtension	?!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
code		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
coding	SΣ	0..*	Coding	Code defined by a terminology system ele-1: All FHIR elements must have a @value or children
system	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
code	Σ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system ele-1: All FHIR elements must have a @value or children Fixed Value: Record artifact
text	SΣ	0..1	string	Plain text representation of the concept ele-1: All FHIR elements must have a @value or children
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section ele-1: All FHIR elements must have a @value or children
entry	SC	1..*	Reference(DocumentReference)	A reference to data that supports this section ele-1: All FHIR elements must have a @value or children
reference	ΣC	1..1	string	Literal reference, Relative, internal or absolute URL ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.section.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes 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()

Differential View

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
status	S	1..1	code	preliminary | final | amended | entered-in-error
type	S	1..1	CodeableConcept	Kind of composition ("Prescription record ")
coding		1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display		1..1	string	Representation defined by the system Fixed Value: Record artifact
text	S	0..1	string	Plain text representation of the concept
subject	S	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about
reference		1..1	string	Literal reference, Relative, internal or absolute URL
encounter		0..1	Reference(Encounter)	Context of the Composition
date	S	1..1	dateTime	Composition editing time
author	S	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record
reference		1..1	string	Literal reference, Relative, internal or absolute URL
title	S	1..1	string	Human Readable name/title
attester	S	0..*	BackboneElement	Attests to accuracy of composition
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition
custodian		0..1	Reference(Organization)	Organization which maintains the composition
section	S	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records.
code
coding	S	0..*	Coding	Code defined by a terminology system
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display		1..1	string	Representation defined by the system Fixed Value: Record artifact
text	S	0..1	string	Plain text representation of the concept
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section
entry	S	1..*	Reference(DocumentReference)	A reference to data that supports this section
reference		1..1	string	Literal reference, Relative, internal or absolute URL
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!SΣ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a 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
coding	Σ	1..1	Coding	Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record
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	1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Record artifact
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient)	Who and/or what the composition/Prescription record is about
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	1..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	0..1	string	Text alternative for the resource
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Composition editing time
author	SΣ	1..*	Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)	Who and/or what authored the composition/Prescription record
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	1..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	0..1	string	Text alternative for the resource
title	SΣ	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	S	0..*	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.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)	Who attested the composition
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
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
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
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
code	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.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	SC	1..1	BackboneElement	The section contains references to documents that represent unstructured historical health records uploaded by patients. These documents can include medical reports, discharge summaries, diagnostic images, and any other relevant health records. 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
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		0..1	string	Label for section (e.g. for ToC)
code		0..1	CodeableConcept	Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
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	SΣ	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	1..1	code	Symbol in syntax defined by the system Fixed Value: 419891008
display	Σ	1..1	string	Representation defined by the system Fixed Value: Record artifact
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	SΣ	0..1	string	Plain text representation of the concept
author		0..*	Reference(Device | RelatedPerson | Organization | Practitioner | PractitionerRole | Organization | Patient)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(DocumentReference)	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	1..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	0..1	string	Text alternative for the resource
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
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	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.author.type	extensible	ResourceType 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	CompositionAttestationMode 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.code	example	DocumentSectionCodes http://hl7.org/fhir/ValueSet/doc-section-codes from the FHIR Standard
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.entry.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason 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()

This structure is derived from Composition

Summary

Mandatory: 10 elements(3 nested mandatory elements)
Must-Support: 12 elements
Fixed: 6 elements

Structures

This structure refers to these other structures:

• Patient (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Patient)
• Encounter (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Encounter)
• Practitioner (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Practitioner)
• Organization (https://nrces.in/ndhm/fhir/r4/StructureDefinition/Organization)
• PractitionerRole (https://nrces.in/ndhm/fhir/r4/StructureDefinition/PractitionerRole)
• DocumentReference (https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference)

Other representations of profile: CSV, Excel, Schematron