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)

Since last visit - Avery Linwood

Composition/generated-summary-avery-20250520 — claims conformance to Composition Profile

{
  "resourceType": "Composition",
  "id": "generated-summary-avery-20250520",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-composition"
    ],
    "security": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationValue",
        "code": "AIAST",
        "display": "Artificial Intelligence asserted"
      }
    ]
  },
  "identifier": {
    "system": "../NamingSystem/nexus-harness-key",
    "value": "since-last-visit-summary:Patient/1234567890"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34133-9",
        "display": "Summary of Episode Note"
      }
    ],
    "text": "Since-last-visit summary"
  },
  "category": [
    {
      "coding": [
        {
          "system": "../CodeSystem/nexus-composition-type",
          "code": "nexus-interval-summary",
          "display": "Interval summary"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-05-20T07:00:00-06:00",
  "author": [
    {
      "type": "Device",
      "identifier": {
        "system": "../NamingSystem/nexus-harness-graph",
        "value": "chart-summary"
      },
      "display": "ChartSummary graph (AI)"
    }
  ],
  "title": "Since last visit - Avery Linwood",
  "event": [
    {
      "period": {
        "start": "2025-04-08T09:00:00-06:00",
        "end": "2025-05-20T07:00:00-06:00"
      }
    }
  ],
  "section": [
    {
      "title": "Since last visit",
      "text": {
        "status": "generated",
        "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Two changes since the 8 April visit. Ferritin rose from 9 to 24 ug/L on 12 May, still below target. Patient telephoned 20 May reporting constipation on iron replacement, managed with docusate; no bleeding, no abdominal pain.</p><p>Outstanding: repeat CBC was ordered 8 April and has not resulted.</p></div>"
      }
    }
  ]
}