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 / Key elements
The working view: must-support, required, modifier and sliced elements from the effective (snapshot) definition.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | An authored clinical note (encounter note, consult note, telephone note) i Invariants: dom-2, dom-3, dom-4, dom-5, dom-6, composition-has-narrative, composition-signed-has-attester |
||
| meta | 0..1 | Meta | Metadata about the resource Invariants: ele-1 |
|
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i Invariants: ele-1 |
| implicitRules | ?! | 0..1 | uri | A set of rules under which this content was created i Invariants: ele-1 |
| text | S | 0..1 | Narrative | Human-readable summary of the note i Invariants: ele-1 |
| identifier | 0..1 | Identifier | Business identifier for the document -- stable across amendments i Invariants: ele-1 |
|
| use | ?! | 0..1 | code | usual | official | temp | secondary | old (If known) i Binding: identifier-use ( required)Invariants: ele-1 |
| system | 1..1 | uri | The namespace for the identifier value i Invariants: ele-1 |
|
| value | 1..1 | string | The value that is unique i Invariants: ele-1 |
|
| status | S ?! | 1..1 | code | preliminary (draft) | final (signed) | amended (edited after signing) | entered-in-error i Binding: composition-status ( required)Invariants: ele-1 |
| 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 · 51852-2Invariants: ele-1 |
| text | S | 0..1 | string | Local document class as the source EMR names it i Invariants: ele-1 |
| 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 …Invariants: ele-1 |
| text | S | 0..1 | string | Plain text refinement, where no code fits i Invariants: ele-1 |
| subject | S | 1..1 | Reference(Patient Profile) | Patient the note is about i Invariants: ele-1 |
| encounter | S | 0..1 | Reference(Encounter Profile) | The encounter this note documents Invariants: ele-1 |
| date | S | 1..1 | dateTime | When the note was last logically changed i Invariants: ele-1 |
| author | S | 1..* | Reference(Practitioner Profile | PractitionerRole Profile | App Device Profile | Device Profile | Device | Organization Profile) | Who or what wrote the note i Invariants: ele-1 |
| title | S | 1..1 | string | Human-readable label for the note i Invariants: ele-1 |
| attester | S | 0..* | BackboneElement | Who signed the note, and when i Invariants: ele-1 |
| mode | S | 1..1 | code | personal | professional | legal | official Binding: composition-attestation-mode ( required)Invariants: ele-1 |
| time | S | 0..1 | dateTime | When the composition was attested Invariants: ele-1 |
| party | S | 1..1 | Reference(Practitioner Profile | PractitionerRole Profile | Organization Profile) | Who attested the composition Invariants: ele-1 |
| custodian | S | 0..1 | Reference(Organization Profile) | Organization responsible for maintaining the note i Invariants: ele-1 |
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents i Invariants: ele-1 |
|
| code | 1..1 | code | replaces | transforms | signs | appends i Binding: document-relationship-type ( required)Invariants: ele-1 |
|
| target[x] | 1..1 | Identifier, Reference(Composition) | Target of the relationship Invariants: ele-1 |
|
| event | S | 0..* | BackboneElement | The care being documented -- what happened, and WHEN it happened i Invariants: ele-1 |
| code | S | 0..* | CodeableConcept | What kind of care this note documents i Binding: v3-ActCode ( example)Invariants: ele-1 |
| period | S | 0..1 | Period | WHEN the documented care happened -- the clinical date. Only 'start' expected Invariants: ele-1 |
| start | S | 1..1 | dateTime | Starting time with inclusive boundary i Invariants: ele-1 |
| detail | S | 0..* | Reference(Resource) | The thing being documented, when it is a resource Invariants: ele-1 |
| section | S | 0..* | BackboneElement | The note body -- narrative in section.textSlicing: pattern:code (open) Invariants: cmp-1, cmp-2, ele-1 |
| title | S | 0..1 | string | Section heading as displayed i Invariants: ele-1 |
| author | S | 0..* | Reference(Practitioner Profile | PractitionerRole Profile | App Device Profile | Device Profile | Device | Organization Profile) | Per-section authorship, where sections have different authors Invariants: ele-1 |
| text | S | 0..1 | Narrative | The section's narrative, as XHTML i Invariants: ele-1 |
| status | S | 1..1 | code | generated | extensions | additional | empty -- a note body is additionalBinding: narrative-status ( required)Invariants: ele-1 |
| div | 1..1 | xhtml | Limited xhtml content i Invariants: ele-1, txt-1, txt-2 |
|
| entry | S | 0..* | Reference(Resource) | Structured resources belonging to this section i Invariants: ele-1 |
| section:enclosures | S | 0..1 | BackboneElement | The attachment packets travelling with this document, one entry each Invariants: cmp-1, cmp-2, ele-1 |
| title | S | 0..1 | string | The heading as displayed -- Enclosures iInvariants: ele-1 |
| code | 1..1 | CodeableConcept | LOINC 28562-7 -- the enclosures section code (display: Chart section Set) iPattern: {"coding":[{"code":"28562-7","system":"http://loinc.org"}]}Binding: Composition Section Value Set ( extensible)e.g. 51847-2 · 55752-0 · 8716-3 …Invariants: ele-1 |
|
| author | S | 0..* | Reference(Practitioner Profile | PractitionerRole Profile | App Device Profile | Device Profile | Device | Organization Profile) | Per-section authorship, where sections have different authors Invariants: ele-1 |
| text | S | 0..1 | Narrative | The section's narrative, as XHTML i Invariants: ele-1 |
| status | S | 1..1 | code | generated | extensions | additional | empty -- a note body is additionalBinding: narrative-status ( required)Invariants: ele-1 |
| div | 1..1 | xhtml | Limited xhtml content i Invariants: ele-1, txt-1, txt-2 |
|
| entry | S | 0..* | Reference(Attachment Packet Profile) | One attachment packet per entry i Invariants: ele-1 |