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)

Progress Note - 8 Apr 2025

Composition/progress-note-avery-20250408 — claims conformance to Composition Profile

{
  "resourceType": "Composition",
  "id": "progress-note-avery-20250408",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-composition"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Signed progress note for Avery Linwood's April 8, 2025 anemia follow-up, authored by Dr. Emil Navarro. Status <code>final</code> with a legal attester, so the note is signed; an edit after this point would update this same resource in place and flip status to <code>amended</code>, with the as-signed text preserved in version history. <code>event.period</code> is the CLINICAL date and matches the encounter it documents (09:00-09:45); <code>date</code> is 11:20, when the note was written up. Sort a timeline by <code>event.period.start</code>, which does not move, not by <code>date</code>, which would.</p></div>"
  },
  "status": "final",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34109-9",
        "display": "Note"
      }
    ],
    "text": "Progress Note"
  },
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "encounter": {
    "reference": "Encounter/enc-avery-20250408-01rc",
    "display": "Anemia follow-up, April 8 2025"
  },
  "date": "2025-04-08T11:20:00-06:00",
  "author": [
    {
      "reference": "Practitioner/dr-emil-navarro",
      "display": "Dr. Emil Navarro"
    }
  ],
  "title": "Progress Note - 8 Apr 2025",
  "attester": [
    {
      "mode": "legal",
      "time": "2025-04-08T11:22:00-06:00",
      "party": {
        "reference": "Practitioner/dr-emil-navarro",
        "display": "Dr. Emil Navarro"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/cedarbrook-clinic"
  },
  "event": [
    {
      "code": [
        {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "185349003",
              "display": "Encounter for check up"
            }
          ]
        }
      ],
      "period": {
        "start": "2025-04-08T09:00:00-06:00",
        "end": "2025-04-08T09:45:00-06:00"
      },
      "detail": [
        {
          "reference": "Encounter/enc-avery-20250408-01rc",
          "display": "Anemia follow-up, April 8 2025"
        }
      ]
    }
  ],
  "section": [
    {
      "title": "Progress Note",
      "text": {
        "status": "additional",
        "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p><strong>Subjective:</strong> Avery returns for follow-up of iron deficiency anemia diagnosed in February. Reports energy has improved substantially over the past six weeks; no longer short of breath climbing stairs. Taking ferrous sulfate 325 mg daily, tolerating well apart from mild constipation managed with dietary fibre. No melena, no heavy menstrual bleeding.</p><p><strong>Objective:</strong> Well-appearing, no conjunctival pallor. Hgb 118 g/L (was 102 in February), ferritin 42 ug/L (was 8). Vitals stable.</p><p><strong>Assessment:</strong> Iron deficiency anemia, responding well to oral replacement. Ferritin still at the low end; stores not yet replete.</p><p><strong>Plan:</strong> Continue ferrous sulfate 325 mg daily for a further three months. Repeat CBC and ferritin at that point. Continue dietary fibre for constipation. Return sooner if fatigue recurs or bleeding develops.</p></div>"
      }
    }
  ],
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "11506-3",
          "display": "Progress Note"
        }
      ]
    }
  ]
}