# Clinical Note Document

26.0.0 AU

Clinical Note Document - Local Development build (v26.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: CND Composition

Official URL: http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-composition | Version: 26.0.0
Active as of 2026-06-19 | Computable Name: CND_Composition
Copyright/Legal: This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/

This profile specialises the FHIR Clinical Document Composition Profile for the purposes of a Clinical Note Document in Australia. All the guidelines and conformance requirements defined of the FHIR Clinical Document Composition apply.

This profile defines the composition structure for a Clinical Note Document in Australia, ensuring consistent organisation of clinical note content including narrative sections and medication information for exchange between healthcare providers.

Usages:

- Use this Profile: CND Bundle
- Examples for this Profile: Composition/ex-composition-anne

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: clindoc-limit-participantType, inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:R5-Composition-version | S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
extension:data-enterer | S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
extension:informant | S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
extension:information-recipient | S | 1..* | (Complex) | Information Recipient Extension URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "type"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:function |  | 0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type.
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "function"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible)
extension:time |  | 0..1 | Extension | Time period of participation
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "time"
value[x] |  | 1..1 | Period | Value of extension
extension:party | S | 1..1 | Extension | Extension
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "party"
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
url |  | 1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
extension:participant | S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
extension:consent | S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
extension:basedOn | S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:change-made | S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
Slices for modifierExtension | ?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url
modifierExtension:R5-Composition-status | ?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
identifier | S Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:clinicalnotecategory | S Σ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 1..1 | string | Representation defined by the system Fixed Value: Clinical note
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:ClinicalNoteCategory | S Σ | 0..1 | CodeableConcept | Clinical Note Document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject | S Σ | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
title | S Σ | 1..1 | string | Human Readable name/title
Slices for attester | S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time | S | 0..1 | dateTime | When the composition was attested
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | aka legal authenticator
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. Required Pattern: legal
attester:professional_attester | S | 0..* | BackboneElement | aka authenticator
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. Required Pattern: professional
custodian | S Σ | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for relatesTo | S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target
relatesTo:All Slices |  |  |  | Content/Rules for all slices
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.
Slices for target[x] |  | 1..1 |  | Target of the relationship Slice: Unordered, Open by type:$this
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
target[x]:targetIdentifier |  | 0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
relatesTo:replaced_document | S | 0..* | BackboneElement | The document(s) being superceded
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. Required Pattern: replaces
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
relatesTo:appended_document | S | 0..* | BackboneElement | The document(s) being appended too
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Target of the relationship
use | ?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Slices for section | S C | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
text | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:sectionNarrative | S C | 0..1 | BackboneElement | Narrative Section Constraints: cmp-1, cmp-2
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S C | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
section:sectionMedications | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S C | 0..* | Reference(Resource) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG
Composition.extension:information-recipient.​extension:function.value[x] | Base | extensible | ParticipationFunction | 📦3.0.0 | THO v7.2
Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std.
Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:ClinicalNoteCategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:legal_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:professional_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.section.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. | `extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()`
cmp-1 | error | Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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()`
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

This structure is derived from ClinicalDocumentComposition

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:information-recipient |  | 1..* | InformationRecipientExtension | Information Recipient Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:party |  | 1..1 | Extension | Extension
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
type |  | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
Slices for category |  |  |  | Content/Rules for all slices
category:ClinicalNoteCategory | S | 0..1 | CodeableConcept | Clinical Note Document Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
text |  | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject |  | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
author |  | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
custodian |  | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for section |  | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code
section:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
section:sectionNarrative | S | 0..1 | BackboneElement | Narrative Section
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
code |  | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
Slices for entry |  | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
section:sectionMedications | S | 0..1 | BackboneElement | Medications Section
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
code |  | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
text |  | 1..1 | Narrative | Text summary of the section, for human interpretation
Slices for entry |  | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S | 0..* | Reference(Resource) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: clindoc-limit-participantType, inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
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 | S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:R5-Composition-version | S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
extension:data-enterer | S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
extension:informant | S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
extension:information-recipient | S | 1..* | (Complex) | Information Recipient Extension URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "type"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:function |  | 0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "function"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible)
extension:time |  | 0..1 | Extension | Time period of participation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "time"
value[x] |  | 1..1 | Period | Value of extension
extension:party | S | 1..1 | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "party"
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
url |  | 1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
extension:participant | S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
extension:consent | S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
extension:basedOn | S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:change-made | S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
Slices for modifierExtension | ?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url
modifierExtension:R5-Composition-status | ?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
identifier | S Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:clinicalnotecategory | S Σ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 1..1 | string | Representation defined by the system Fixed Value: Clinical note
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:ClinicalNoteCategory | S Σ | 0..1 | CodeableConcept | Clinical Note Document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject | S Σ | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
title | S Σ | 1..1 | string | Human Readable name/title
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
Slices for attester | S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time | S | 0..1 | dateTime | When the composition was attested
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | aka legal authenticator
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. Required Pattern: legal
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:professional_attester | S | 0..* | BackboneElement | aka authenticator
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. Required Pattern: professional
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
custodian | S Σ | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for relatesTo | S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target
relatesTo:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
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.
Slices for target[x] |  | 1..1 |  | Target of the relationship Slice: Unordered, Open by type:$this
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
target[x]:targetIdentifier |  | 0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
relatesTo:replaced_document | S | 0..* | BackboneElement | The document(s) being superceded
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. Required Pattern: replaces
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
relatesTo:appended_document | S | 0..* | BackboneElement | The document(s) being appended too
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Target of the relationship
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
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
Slices for section | S C | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | C | 0..* | Reference(Resource) | A reference to data that supports this section
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
section:sectionNarrative | S C | 0..1 | BackboneElement | Narrative Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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.
Slices for entry | C | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S C | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
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
section:sectionMedications | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 1..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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.
Slices for entry | C | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S C | 0..* | Reference(Resource) | A reference to data that supports this section
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 | Status | Usage | ValueSet | Version | Source
Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG
Composition.extension:information-recipient.​extension:function.value[x] | Base | extensible | ParticipationFunction | 📦3.0.0 | THO v7.2
Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std.
Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:ClinicalNoteCategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std.
Composition.attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:legal_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:professional_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.2
Composition.section.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. | `extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()`
cmp-1 | error | Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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()`
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

This structure is derived from ClinicalDocumentComposition

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 5 elements

Structures

This structure refers to these other structures:

- CND Organization (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-organization)
- CND Department (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-department)
- CND PractitionerRole (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-practitionerrole)
- CND Patient (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-patient)
- CND DocumentReference (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-documentreference)
- CND MedicationStatement (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-medicationstatement)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/note|5.3.0

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Composition.section
- The element 1 is sliced based on the value of Composition.section.entry

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: clindoc-limit-participantType, inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created
language | S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:R5-Composition-version | S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
extension:data-enterer | S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
extension:informant | S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
extension:information-recipient | S | 1..* | (Complex) | Information Recipient Extension URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "type"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:function |  | 0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type.
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "function"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible)
extension:time |  | 0..1 | Extension | Time period of participation
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "time"
value[x] |  | 1..1 | Period | Value of extension
extension:party | S | 1..1 | Extension | Extension
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "party"
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
url |  | 1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
extension:participant | S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
extension:consent | S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
extension:basedOn | S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:change-made | S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
Slices for modifierExtension | ?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url
modifierExtension:R5-Composition-status | ?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
identifier | S Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:clinicalnotecategory | S Σ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 1..1 | string | Representation defined by the system Fixed Value: Clinical note
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:ClinicalNoteCategory | S Σ | 0..1 | CodeableConcept | Clinical Note Document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject | S Σ | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
title | S Σ | 1..1 | string | Human Readable name/title
Slices for attester | S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time | S | 0..1 | dateTime | When the composition was attested
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | aka legal authenticator
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. Required Pattern: legal
attester:professional_attester | S | 0..* | BackboneElement | aka authenticator
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. Required Pattern: professional
custodian | S Σ | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for relatesTo | S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target
relatesTo:All Slices |  |  |  | Content/Rules for all slices
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.
Slices for target[x] |  | 1..1 |  | Target of the relationship Slice: Unordered, Open by type:$this
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
target[x]:targetIdentifier |  | 0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
relatesTo:replaced_document | S | 0..* | BackboneElement | The document(s) being superceded
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. Required Pattern: replaces
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
relatesTo:appended_document | S | 0..* | BackboneElement | The document(s) being appended too
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Target of the relationship
use | ?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
Slices for section | S C | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
text | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
section:sectionNarrative | S C | 0..1 | BackboneElement | Narrative Section Constraints: cmp-1, cmp-2
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S C | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
section:sectionMedications | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
text | S C | 1..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
Slices for entry | C | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S C | 0..* | Reference(Resource) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG
Composition.extension:information-recipient.​extension:function.value[x] | Base | extensible | ParticipationFunction | 📦3.0.0 | THO v7.2
Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std.
Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:ClinicalNoteCategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:legal_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:professional_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.section.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. | `extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()`
cmp-1 | error | Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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()`
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

Differential View

This structure is derived from ClinicalDocumentComposition

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
extension |  | 1..* | Extension | Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:information-recipient |  | 1..* | InformationRecipientExtension | Information Recipient Extension
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:party |  | 1..1 | Extension | Extension
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
type |  | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
Slices for category |  |  |  | Content/Rules for all slices
category:ClinicalNoteCategory | S | 0..1 | CodeableConcept | Clinical Note Document Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
text |  | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject |  | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
author |  | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
custodian |  | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for section |  | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code
section:All Slices |  |  |  | Content/Rules for all slices
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
section:sectionNarrative | S | 0..1 | BackboneElement | Narrative Section
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
code |  | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
Slices for entry |  | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
section:sectionMedications | S | 0..1 | BackboneElement | Medications Section
Slices for extension |  |  |  | Content/Rules for all slices
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
code |  | 1..1 | CodeableConcept | Classification of section (recommended) Required Pattern: At least the following
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
text |  | 1..1 | Narrative | Text summary of the section, for human interpretation
Slices for entry |  | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S | 0..* | Reference(Resource) | A reference to data that supports this section
Documentation for this format

#### Terminology Bindings (Differential)

Path | Status | Usage | ValueSet | Version | Source
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG

#### Constraints

Id | Grade | Path(s) | Description | Expression
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
Composition | C | 0..* | ClinicalDocumentComposition | Clinical Note Document Composition Constraints: clindoc-limit-participantType, inv-01-narrative-or-medications-section, inv-02-narrative-text-or-entry
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 | S | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
text | S | 0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained |  | 0..* | Resource | Contained, inline Resources
Slices for extension |  | 1..* | Extension | Extension Slice: Unordered, Open by value:url
extension:R5-Composition-version | S | 0..1 | string | Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.version
extension:data-enterer | S | 0..1 | (Complex) | A Data Enterer represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author's information to the electronic system. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/data-enterer-extension
extension:informant | S | 0..* | (Complex) | An Informant is an information source for any content within the clinical document. This informant is constrained for use when the source of information is an assigned health care provider for the patient. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/informant-extension
extension:information-recipient | S | 1..* | (Complex) | Information Recipient Extension URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 2..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:type |  | 1..* | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "type"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: Information Recipient Type (required)
extension:function |  | 0..* | Extension | Exact function of the participant in the creation of the clinical document. This is more granular than type.
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "function"
value[x] |  | 1..1 | CodeableConcept | Value of extension Binding: ParticipationFunction (extensible)
extension:time |  | 0..1 | Extension | Time period of participation
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "time"
value[x] |  | 1..1 | Period | Value of extension
extension:party | S | 1..1 | Extension | Extension
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..0 |  | Extension Slice: Unordered, Open by value:url
url |  | 1..1 | uri | "party"
value[x] |  | 1..1 | Reference(CND Organization | CND Department | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
url |  | 1..1 | uri | "http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/information-recipient-extension"
extension:participant | S | 0..* | (Complex) | A Participant that is not a data-enter, information-recipient nor an informant URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension
extension:consent | S | 0..* | Reference(Consent) | consent URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/consent-extension
extension:basedOn | S | 0..* | Reference(Resource) | The clinical action, such as a plan, proposal or order that is fulfilled by or precipitated this FHIR Clinical Document, such as a radiologists report of an x-ray. URL: http://hl7.org/fhir/StructureDefinition/event-basedOn
extension:change-made | S | 0..1 | (Complex) | Note of changes made, calculating changes maybe required for safety as this extension may not contain all changes. Experimental, may overlap with other elements such as FHIR R6 note. URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
Slices for modifierExtension | ?! | 0..* | Extension | Extension Slice: Unordered, Open by value:url
modifierExtension:R5-Composition-status | ?!S | 0..1 | base64Binary, boolean, canonical(), code, date, dateTime, decimal, id, instant, integer, markdown, oid, positiveInt, string, time, unsignedInt, uri, url, uuid, Address, Age, Annotation, Attachment, CodeableConcept, Coding, ContactPoint, Count, Distance, Duration, HumanName, Identifier, Money, Period, Quantity, Range, Ratio, Reference(), SampledData, Signature, Timing, ContactDetail, Contributor, DataRequirement, Expression, ParameterDefinition, RelatedArtifact, TriggerDefinition, UsageContext, Dosage, Meta | This allows for additional status values found in R5. However, exercise caution as the R4 Composition.status is required. URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-Composition.status
identifier | S Σ | 0..1 | Identifier | Version-independent identifier for the Composition
status | ?!Σ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type | S Σ | 1..1 | CodeableConcept | Kind of composition (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32054
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of Composition Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:clinicalnotecategory | S Σ | 1..1 | CodeableConcept | Category for Clinical Note Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 1..1 | string | Representation defined by the system Fixed Value: Clinical note
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category:ClinicalNoteCategory | S Σ | 0..1 | CodeableConcept | Clinical Note Document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
coding | Σ | 0..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 100.32053
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text | Σ | 0..1 | string | Plain text representation of the concept Required Pattern: Residential Care Clinical Document
subject | S Σ | 1..1 | Reference(CND Patient) | Who and/or what the composition is about
encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition
date | S Σ | 1..1 | dateTime | Composition editing time
author | S Σ | 1..1 | Reference(CND Organization | CND PractitionerRole) | If Practitioner details are known, use PractitionerRole profile. Otherwise, use the Organization profile.
title | S Σ | 1..1 | string | Human Readable name/title
confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
Slices for attester | S | 0..* | BackboneElement | Attests to accuracy of composition Slice: Unordered, Open by value:mode
attester:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
mode | S | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time | S | 0..1 | dateTime | When the composition was attested
party | S | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:legal_attester | S | 0..1 | BackboneElement | aka legal authenticator
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. Required Pattern: legal
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
attester:professional_attester | S | 0..* | BackboneElement | aka authenticator
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. Required Pattern: professional
time |  | 0..1 | dateTime | When the composition was attested
party |  | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition
custodian | S Σ | 0..1 | Reference(CND Organization) | Organization which maintains the composition
Slices for relatesTo | S | 0..* | BackboneElement | Relationships to other compositions/documents Slice: Unordered, Open by value:code, type:target
relatesTo:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
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.
Slices for target[x] |  | 1..1 |  | Target of the relationship Slice: Unordered, Open by type:$this
targetIdentifier |  |  | Identifier |
targetReference |  |  | Reference(Composition) |
target[x]:targetIdentifier |  | 0..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being appended, or to some other identifier of a non FHIR document
relatesTo:replaced_document | S | 0..* | BackboneElement | The document(s) being superceded
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. Required Pattern: replaces
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Reference to the Bundle.identifier of the FHIR Clinical Document being replaced, or to some other identifier of a non FHIR document
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 1..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
relatesTo:appended_document | S | 0..* | BackboneElement | The document(s) being appended too
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code |  | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. Required Pattern: appends
Slices for target[x] |  | 1..1 | Identifier | Target of the relationship Slice: Unordered, Closed by type:$this
Slices for target[x] |  |  |  | Content/Rules for all slices
target[x]:targetIdentifier |  | 1..1 | Identifier | Target of the relationship
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
use | ?!Σ | 1..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value | Σ | 0..1 | string | The value that is unique Example General: 123456
period | Σ | 0..1 | Period | Time period when id is/was valid for use
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text)
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
Slices for section | S C | 1..* | BackboneElement | Sections composing the Clinical Note Document. Slice: Unordered, Open by pattern:code Constraints: cmp-1, cmp-2
section:All Slices |  |  |  | Content/Rules for all slices
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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 | C | 0..* | Reference(Resource) | A reference to data that supports this section
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
section:sectionNarrative | S C | 0..1 | BackboneElement | Narrative Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 61149-1
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 0..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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.
Slices for entry | C | 0..* | Reference(DocumentReference) | Attachments that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:attachment | S C | 0..* | Reference(CND DocumentReference) | A reference to data that supports this section
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
section:sectionMedications | S C | 0..1 | BackboneElement | Medications Section Constraints: cmp-1, cmp-2
id |  | 0..1 | string | Unique id for inter-element referencing
Slices for extension |  | 0..* | Extension | Extension Slice: Unordered, Open by value:url
Slices for extension |  |  |  | Content/Rules for all slices
extension:change-made | S | 0..1 | (Complex) | Change Made URL: http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ChangeMade
extension:section-note |  | 0..1 | Annotation | Additional notes that apply to the section (but not to a specific resource). URL: http://hl7.org/fhir/StructureDefinition/note
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
title | S | 1..1 | string | Label for section (e.g. for ToC)
code | S | 1..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 10160-0
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
author |  | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | 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 | S C | 1..1 | Narrative | Text summary of the section, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
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.
Slices for entry | C | 0..* | Reference(CND MedicationStatement) | Medication statements that are relevant to this section. Slice: Unordered, Open by profile:resolve()
Slices for entry |  |  |  | Content/Rules for all slices
entry:medicationStatement | S C | 0..* | Reference(Resource) | A reference to data that supports this section
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 | Status | Usage | ValueSet | Version | Source
Composition.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
Composition.extension:information-recipient.​extension:type.value[x] | Base | required | Information Recipient Type | 📦26.0.0 | This IG
Composition.extension:information-recipient.​extension:function.value[x] | Base | extensible | ParticipationFunction | 📦3.0.0 | THO v7.2
Composition.status | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std.
Composition.type | Base | preferred | FHIR Document Type Codes | 📍4.0.1 | FHIR Std.
Composition.category | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:clinicalnotecategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.category:ClinicalNoteCategory | Base | example | Document Class Value Set | 📍4.0.1 | FHIR Std.
Composition.confidentiality | Base | required | V3 Value SetConfidentialityClassification | 📍2014-03-26 | FHIR Std.
Composition.attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:legal_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.attester:professional_attester.​mode | Base | required | CompositionAttestationMode | 📍4.0.1 | FHIR Std.
Composition.relatesTo.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:replaced_document.​target[x]:targetIdentifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​use | Base | required | IdentifierUse | 📍4.0.1 | FHIR Std.
Composition.relatesTo:appended_document.​target[x]:targetIdentifier.​type | Base | extensible | IdentifierType | 📍4.0.1 | FHIR Std.
Composition.event.code | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.2
Composition.section.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionNarrative.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​code | Base | example | Document Section Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​mode | Base | required | ListMode | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​orderedBy | Base | preferred | List Order Codes | 📍4.0.1 | FHIR Std.
Composition.section:sectionMedications.​emptyReason | Base | preferred | List Empty Reasons | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
clindoc-limit-participantType | error | Composition | The R4 FHIR Clinical Document Composition Profile contains specific extensions for data entry person, informant, information recipient, primary information recipient and tracker. So, they are not allowed in the participant extension in the R4 profile. In R6, the intention is to have dedicated-named slices of a backbone element. | `extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='ENT').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='INF').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='IRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='PRCP').not() and extension.where(url='http://hl7.org/fhir/uv/fhir-clinical-document/StructureDefinition/ParticipantExtension').extension.where(url='type').value.coding.exists(system='http://terminology.hl7.org/CodeSystem/v3-ParticipationType' and code='TRC').not()`
cmp-1 | error | Composition.section, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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, Composition.section:sectionNarrative, Composition.section:sectionMedications | 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()`
inv-01-narrative-or-medications-section | error | Composition | Composition must have either a sectionNarrative or a sectionMedications section. | `section.where(code.coding.where(code = '61149-1').exists()).exists() or section.where(code.coding.where(code = '10160-0').exists()).exists()`
inv-02-narrative-text-or-entry | error | Composition | section[sectionNarrative] must have either text or at least one entry with a DocumentReference. | `section.where(code.coding.where(code = '61149-1').exists()).all(text.exists() or entry.resolve().ofType(DocumentReference).exists())`

This structure is derived from ClinicalDocumentComposition

Summary

Mandatory: 2 elements(3 nested mandatory elements)
Must-Support: 5 elements

Structures

This structure refers to these other structures:

- CND Organization (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-organization)
- CND Department (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-department)
- CND PractitionerRole (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-practitionerrole)
- CND Patient (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-patient)
- CND DocumentReference (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-documentreference)
- CND MedicationStatement (http://digitalhealth.gov.au/fhir/cnd/StructureDefinition/cnd-medicationstatement)

Extensions

This structure refers to these extensions:

- http://hl7.org/fhir/StructureDefinition/note|5.3.0

Slices

This structure defines the following Slices:

- The element 1 is sliced based on the value of Composition.section
- The element 1 is sliced based on the value of Composition.section.entry

Other representations of profile: CSV, Excel, Schematron