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Author and Recipient

Accurate and complete information about the author and recipient of a Clinical Note Document is essential for creating a conformant document. This page provides specific guidance on how to populate author and recipient details within the context of this Implementation Guide, setting clear expectations for both sending and receiving systems. The aim is to eliminate any ambiguity, thereby enhancing consistency and interoperability.

Author Information

The author of the Clinical Note Document is the responsible provider or organisation for the whole document. Keeping in mind that this is not necessarily who typed it in. Below are key notes that implementers need to keep in mind regarding the author of the Clinical Note Document:

  • Document author information is captured in the Composition.author element within the CND- Composition Profile. This is a mandatory element that SHALL be populated. Each document SHALL have only one author.
  • FHIR Composition allows for a section level author to be captured in Composition.section.author. However, this Implementation Guide doesn't provide additional guidance or set any expectations on sending and receiving systems regarding this element. This MAY change in future releases based on feedback from the community.
  • The CND Composition Profile derives from the FHIR Clinical Document Composition Profile which results in the following elements being described in the Clinical Note Document specification, Composition.extension(data-enterer), Composition.extension(informant), and Composition.extension(information-recipient). The Clinical Note Document inherits the MUST Support flag on these elements. In the context of this Implementation Guide, this means that sending systems SHOULD populate this information if available, while receiving systems SHALL NOT error if this information is present. This Implementation Guide doesn't provide additional guidance regarding these elements. This MAY change in future releases based on feedback from the community.
  • There are two options to populate the author information of a Clinical Note Document:
    • If the provider details are known, Composition.author SHALL reference an instance of CND PractitionerRole Profile where both practitioner and organisation details are made mandatory.

    • If the provider details are not known, Composition.author SHALL reference an instance of CND Organization Profile.

    • This means that at a minimum the authoring organisation details SHALL be provided.
  • Note: Composition.custodian is a mandatory element. In some cases, it will be the same as the authoring organisation but it can be different in other scenarios, for example a parent organisation being the custodian while one of its members within a hierarchy is the authoring organisation.

Recipient Information

Below are key notes that implementers need to keep in mind regarding the recipient of the Clinical Note Document:

  • Document recipient information is captured in Composition.extension[information-recipient] element within the CND Composition Profile. This is a mandatory element that SHALL be populated. Each document SHALL have one or more recipient.
  • Information Recipient is a complex extension from the FHIR Clinical Documents Implementation Guide.
  • Each information recipient SHALL have a type which SHALL come from Information Recipient Type Value Set.
  • There are three options to populate the recipient information of a Clinical Note Document:
    • If the provider details are known, Composition.extension[information-recipient].extension[party] SHALL reference an instance of CND PractitionerRole Profile with details for both practitioner and organisation.
    • If the provider details are not known, Composition.extension[information-recipient].extension[party] SHALL reference an instance of CND Organization Profile or an instance of CND Department Profile with details for both practitioner and organisation.
    • This means that at a minimum the recipient organisation details SHALL be provided.