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)

Telephone Note - 20 May 2025 (amended)

Composition/scribed-note-avery-20250520-amended — claims conformance to Composition Profile

{
  "resourceType": "Composition",
  "id": "scribed-note-avery-20250520-amended",
  "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>An AI-scribed note that was signed and then corrected. Three things this example exists to show.</p><p><strong>The label.</strong> <code>meta.security</code> carries <code>AIAST</code>, because a machine produced the text this note started from. It stays on the resource after the clinician edited and signed it: the label describes how the content came to be, and signing does not undo that. Attestation is the separate axis, and this note carries both.</p><p><strong>Origin.</strong> Two authors: the SmartDocs AI Scribe Device that drafted the text, and Dr. Navarro who is medically responsible. The Device is an author; only the clinician attests. Absence of a Device author means origin <em>unknown</em>, not &quot;typed&quot;.</p><p><strong>Amendment.</strong> Status is <code>amended</code>, and this is the SAME resource, under the SAME <code>id</code>, as when it was signed -- the correction was an in-place update, not a second Composition related back to the first. The as-signed text lives in this resource's version history. Note <code>date</code> has moved to the amendment time (11:05) while <code>attester.time</code> still records the original signature (09:47), which is why <code>date</code> must not be read as the authored date. <code>event.period.start</code> stays where the care happened -- the 09:40 telephone call -- and is the only one of the three that did not move. A timeline sorting these notes by <code>date</code> jumps this one forward by 85 minutes; sorting by <code>event.period.start</code> leaves it on the call.</p></div>"
  },
  "status": "amended",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34109-9",
        "display": "Note"
      }
    ],
    "text": "Telephone Note"
  },
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-05-20T11:05:00-06:00",
  "author": [
    {
      "reference": "Practitioner/dr-emil-navarro",
      "display": "Dr. Emil Navarro"
    },
    {
      "identifier": {
        "system": "../NamingSystem/nexus-emr-appdevice-identifier",
        "value": "smartdocs-ai-scribe"
      },
      "display": "SmartDocs AI Scribe"
    }
  ],
  "title": "Telephone Note - 20 May 2025 (amended)",
  "attester": [
    {
      "mode": "legal",
      "time": "2025-05-20T09:47:00-06:00",
      "party": {
        "reference": "Practitioner/dr-emil-navarro",
        "display": "Dr. Emil Navarro"
      }
    }
  ],
  "custodian": {
    "reference": "Organization/cedarbrook-clinic"
  },
  "event": [
    {
      "code": [
        {
          "coding": [
            {
              "system": "http://snomed.info/sct",
              "code": "185317003",
              "display": "Telephone encounter"
            }
          ]
        }
      ],
      "period": {
        "start": "2025-05-20T09:40:00-06:00"
      }
    }
  ],
  "section": [
    {
      "title": "Telephone Note",
      "text": {
        "status": "additional",
        "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Patient telephoned regarding constipation on iron replacement. Reports symptoms manageable but bothersome, particularly in the mornings. No abdominal pain, no bleeding, appetite normal.</p><p>Advised to continue ferrous sulfate and increase dietary fibre and fluids; discussed taking the dose with food if tolerance worsens, accepting slightly reduced absorption. Patient comfortable with the plan and will call back if symptoms escalate.</p><p><em>Addendum 11:05 -- corrected dose: patient is on ferrous sulfate 325 mg ONCE daily, not twice as originally recorded. Confirmed against the medication list and with the patient by callback.</em></p></div>"
      }
    }
  ],
  "category": [
    {
      "coding": [
        {
          "system": "http://loinc.org",
          "code": "34748-4",
          "display": "Telephone Encounter Note"
        }
      ]
    }
  ]
}