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.
Elements / Differential
What this profile constrains beyond Composition. Anything not listed is unchanged from the base; muted type/cardinality values are the base's, shown for context.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | An authored clinical note (encounter note, consult note, telephone note) i Invariants: composition-has-narrative, composition-signed-has-attester |
|||
| meta | 0..1 | Meta | ||
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i |
| text | S | 0..1 | Narrative | Human-readable summary of the note i |
| identifier | 0..1 | Identifier | Business identifier for the document -- stable across amendments i | |
| system | 1..1 | uri | i | |
| value | 1..1 | string | i | |
| status | S | 1..1 | code | preliminary (draft) | final (signed) | amended (edited after signing) | entered-in-error i Binding: composition-status ( required) |
| type | S | 1..1 | CodeableConcept | What kind of document this is: note, summary or letter i Binding: Composition Classification Value Set ( extensible)e.g. 34109-9 · 34133-9 · 51852-2 |
| text | S | 0..1 | string | Local document class as the source EMR names it i |
| category | S | 0..* | CodeableConcept | Refinements of the type: which kind of note, which kind of summary i Binding: Composition Kind Value Set ( preferred)e.g. 34109-9 · 34133-9 · 51852-2 … |
| text | S | 0..1 | string | Plain text refinement, where no code fits i |
| subject | S | 1..1 | Reference(Patient Profile) | Patient the note is about i |
| encounter | S | 0..1 | Reference(Encounter Profile) | The encounter this note documents |
| date | S | 1..1 | dateTime | When the note was last logically changed i |
| author | S | 1..* | Reference(Practitioner Profile | PractitionerRole Profile | App Device Profile | Device Profile | Device | Organization Profile) | Who or what wrote the note i |
| title | S | 1..1 | string | Human-readable label for the note i |
| confidentiality | 0..1 | code | Confidentiality level, where the EMR distinguishes i | |
| attester | S | 0..* | BackboneElement | Who signed the note, and when i |
| mode | S | 1..1 | code | |
| time | S | 0..1 | dateTime | |
| party | S | 1..1 | Reference(Practitioner Profile | PractitionerRole Profile | Organization Profile) | |
| custodian | S | 0..1 | Reference(Organization Profile) | Organization responsible for maintaining the note i |
| event | S | 0..* | BackboneElement | The care being documented -- what happened, and WHEN it happened i |
| code | S | 0..* | CodeableConcept | What kind of care this note documents i |
| period | S | 0..1 | Period | WHEN the documented care happened -- the clinical date. Only 'start' expected |
| start | S | 1..1 | dateTime | i |
| detail | S | 0..* | Reference(Resource) | The thing being documented, when it is a resource |
| section | S | 0..* | BackboneElement | The note body -- narrative in section.textSlicing: pattern:code (open) |
| title | S | 0..1 | string | Section heading as displayed i |
| code | 0..1 | CodeableConcept | What the section clinically IS -- a SECTION code, never a document code i Binding: Composition Section Value Set ( extensible)e.g. 51847-2 · 55752-0 · 8716-3 … |
|
| author | S | 0..* | Reference(Practitioner Profile | PractitionerRole Profile | App Device Profile | Device Profile | Device | Organization Profile) | Per-section authorship, where sections have different authors |
| text | S | 0..1 | Narrative | The section's narrative, as XHTML i |
| status | S | 1..1 | code | generated | extensions | additional | empty -- a note body is additional |
| entry | S | 0..* | Reference(Resource) | Structured resources belonging to this section i |
| emptyReason | 0..1 | CodeableConcept | Why an expected section is empty i | |
| section:enclosures | S | 0..1 | BackboneElement | The attachment packets travelling with this document, one entry each |
| title | 0..1 | string | The heading as displayed -- Enclosures i |
|
| code | 1..1 | CodeableConcept | LOINC 28562-7 -- the enclosures section code (display: Chart section Set) iPattern: {"coding":[{"code":"28562-7","system":"http://loinc.org"}]} |
|
| entry | 0..* | Reference(Attachment Packet Profile) | One attachment packet per entry i |