Composition Profile

Canonical	../StructureDefinition/nexus-emr-core-composition
Status	draft · 1.26.0
Base	Composition (constraint)
Source	FSH · JSON

Nexus EMR profile for an AUTHORED clinical note -- principally the encounter note (progress note, consult note, telephone note) written by an EMR user or drafted by an AI scribe and attested by a clinician.

Examples

AI Pre-Visit Summary (cited document) · Progress Note - 8 Apr 2025 · Referral - Internal Medicine - Avery Linwood · Signed Encounter Note (extraction source) · Since last visit - Avery Linwood · Since last visit - Avery Linwood (converted) · Telephone Note - 20 May 2025 (amended)

Signed Encounter Note (extraction source)

The signed note whose prose states type 2 diabetes without it being on the problem list -- the passage the chart-update extraction quotes when it suggests the addition. No identifier, because the note originated here and reconciles to no source system, and the profile prefers an empty slot to a business identifier that keys into nothing

Composition/encounter-note-avery-20260810 — claims conformance to Composition Profile

{
  "resourceType": "Composition",
  "id": "encounter-note-avery-20260810",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-composition"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Signed encounter note for Avery Linwood's 10 August 2026 visit, written and attested by Dr. Ben. The note states type 2 diabetes in prose without it having been added to the problem list, which is the passage the chart-update extraction later quotes when it suggests the addition.</p><p>No <code>identifier</code>: this note originated here and reconciles to no source system, and the profile prefers an empty slot to a business identifier that keys into nothing.</p></div>"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34109-9",
        "display": "Note"
      }
    ],
    "text": "Encounter Note"
  },
  "subject": {
    "reference": "Patient/nexus-emr-patient-attachment-example",
    "display": "Avery Linwood"
  },
  "date": "2026-08-10T14:05:00-04:00",
  "author": [
    {
      "reference": "PractitionerRole/dr-ben-mrp-role",
      "display": "Dr. Ben"
    }
  ],
  "title": "Encounter Note - 10 Aug 2026",
  "attester": [
    {
      "mode": "legal",
      "time": "2026-08-10T14:10:00-04:00",
      "party": {
        "reference": "PractitionerRole/dr-ben-mrp-role",
        "display": "Dr. Ben"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/cedarbrook-clinic"
  },
  "event": [
    {
      "period": {
        "start": "2026-08-10T13:40:00-04:00",
        "end": "2026-08-10T14:00:00-04:00"
      }
    }
  ],
  "section": [
    {
      "title": "Encounter Note",
      "text": {
        "status": "additional",
        "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p><strong>Subjective:</strong> Attends for routine review. Longstanding type 2 diabetes, diet-controlled, last A1c 6.9. No polyuria, no visual change, no foot symptoms. Taking warfarin as prescribed; no bleeding.</p><p><strong>Objective:</strong> Weight stable. BP 128/78. Feet examined, monofilament sensation intact bilaterally, no lesions.</p><p><strong>Assessment:</strong> Type 2 diabetes, well controlled on diet alone. Anticoagulation stable.</p><p><strong>Plan:</strong> Repeat A1c and lipids in three months. Retinal screening due; referral sent. Continue current management.</p></div>"
      }
    }
  ],
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "11506-3",
          "display": "Progress Note"
        }
      ]
    }
  ]
}

Referenced by: Suggested-Resource Task - Add a Chart Entry