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)

AI Pre-Visit Summary (cited document)

The machine-generated summary the per-fact citation Provenance targets. Its section text carries the same statements that Provenance attributes to sources, so the chain is checkable end to end. date is the evening it was generated, event.period.start is the appointment it was written for, and the absence of an attester is correct rather than missing -- nothing attests to a machine-generated summary

Composition/previsit-summary-avery-20250409 — claims conformance to Composition Profile

{
  "resourceType": "Composition",
  "id": "previsit-summary-avery-20250409",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-composition"
    ],
    "security": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ObservationValue",
        "code": "AIAST",
        "display": "Artificial Intelligence asserted"
      }
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Machine-generated pre-visit summary for Avery Linwood, produced on the evening of 8 April 2025 ahead of her appointment the following morning. This is the document the per-fact citation Provenance targets: every statement in the section below is one of the statements that Provenance attributes to a source, so the citations can be checked against the text they claim to summarise.</p><p><code>date</code> is 8 April, when the summary was generated; <code>event.period.start</code> is 9 April, the appointment it was written for. No attester, and that absence is correct rather than missing -- nothing attests to a machine-generated summary.</p></div>"
  },
  "identifier": {
    "system": "../NamingSystem/nexus-harness-key",
    "value": "previsit-summary:Patient/avery-linwood"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34133-9",
        "display": "Summary of Episode Note"
      }
    ],
    "text": "Pre-visit summary"
  },
  "category": [
    {
      "coding": [
        {
          "system": "../CodeSystem/nexus-composition-type",
          "code": "nexus-daysheet-summary",
          "display": "Day-sheet summary"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-04-08T18:00:00-06:00",
  "author": [
    {
      "reference": "Device/smartdocs-ai-scribe",
      "display": "SmartDocs AI Scribe"
    }
  ],
  "title": "Pre-visit summary - appointment of 9 Apr 2025",
  "event": [
    {
      "period": {
        "start": "2025-04-09T09:00:00-06:00"
      }
    }
  ],
  "section": [
    {
      "title": "Pre-visit summary",
      "text": {
        "status": "generated",
        "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Cardiology consult of 2025-03-22 recommends continuing warfarin at the current dose.</p><p>Most recent INR (2025-04-02) was 2.4, within the target range of 2.0 to 3.0.</p></div>"
      }
    }
  ]
}

Referenced by: AI-Generated Summary With Per-Fact Citations