CDA On FHIR England - Document Header

COFE-Composition-1

CDA On FHIR Document Header Composition

NameCard.TypeDescription & Constraints
..CompositionCompositionA set of resources composed into a single coherent clinical statement with clinical attestation

...Data Enterer Extension0..1ExtensionExtension for data enterer (transcriptionist).
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-data-enterer-1

...Informant Extension0..*ExtensionExtension for informant.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-informant-1

...Information Recipient Extension0..*ExtensionExtension for information recipient.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-information-recipient-1

...Participant Extension0..*ExtensionExtension for participant.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-participant-1

...Performer Extension0..*ExtensionExtension for performer.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-performer-1

...Authorization Extension0..*ExtensionExtension for authorization.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-authorization-1

...identifier1..1IdentifierLogical identifier of composition (version-independent)

....value1..1StringContains a DCE UUID
Example Value 871985a7-45f9-435a-89fa-fcedd7afa7a3

...date1..1DateTimeComposition editing time

...type1..1CodeableConceptA set of codes to classify the type of document.
Binding Type of document. (http://fhir.nhs.net/ValueSet/document-type-1)
Binding Strength Preferred

....CareSettingType0..1ExtensionThe care setting in which the patient was present.
Extension http://fhir.nhs.net/StructureDefinition/extension-cofe-care-setting-type-1

....coding1..1CodingCode defined by a terminology system
Binding Type of a document. (http://fhir.nhs.net/ValueSet/document-type-1)
Binding Strength Preferred

.....system1..1UriIdentity of the terminology system
Fixed Value http://snomed.info/sct

.....code1..1CodeA set of codes to classify the type of document.
Binding A set of codes to classify the type of document. (http://fhir.nhs.net/ValueSet/document-type-1)
Binding Strength Preferred
Example Value 373942005

.....display1..1StringRepresentation defined by the system
Example Value Discharge summary

...class0..1CodeableConceptCategorization of Composition
Binding High-level kind of a clinical document at a macro level. (http://hl7.org/fhir/ValueSet/doc-classcodes)
Binding Strength Example

...title1..1StringHuman Readable name/title

...status1..1Codepreliminary | final | amended | entered-in-error
Binding The workflow/clinical status of the composition. (http://hl7.org/fhir/ValueSet/composition-status)
Binding Strength Required

...confidentiality1..1CodeAs defined by affinity domain
Binding Codes specifying the level of confidentiality of the composition. (http://hl7.org/fhir/ValueSet/v3-Confidentiality)
Binding Strength Required

...subject1..1Reference (careconnect-patient-1)Who and/or what the composition is about

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...author1..*Reference (careconnect-practitioner-1 | cofe-device-1)Who and/or what authored the composition

...attester0..*BackboneElementAttests to accuracy of composition

....mode1..*Codepersonal | professional | legal | official
Binding The way in which a person authenticated a composition. (http://hl7.org/fhir/ValueSet/composition-attestation-mode)
Binding Strength Required

....time0..1DateTimeWhen composition attested

....party0..1Reference (careconnect-practitioner-1 | careconnect-patient-1)Who attested the composition

...custodian1..1Reference (careconnect-organization-1)Organization which maintains the composition

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...event0..*BackboneElementThe clinical service(s) being documented

....code0..*CodeableConceptCode(s) that apply to the event being documented
Binding This list of codes represents the main clinical acts being documented. It uses a code from any vocabulary to describe the type of service event. The vocabulary SnomedCT is a preferred vocabulary. (http://snomed.info/sct)
Binding Strength Preferred

.....coding0..*CodingCode defined by a terminology system
Binding A code defined by SNOMED CT (http://snomed.info/sct)
Binding Strength Preferred

......system0..1UriIdentity of the terminology system
Fixed Value http://snomed.info/sct

......code0..1CodeSymbol in syntax defined by the system

......display0..1StringRepresentation defined by the system

.....text0..1StringPlain text representation of the concept

....period0..1PeriodThe period covered by the documentation

.....start0..1DateTimeStarting time with inclusive boundary

.....end0..1DateTimeEnd time with inclusive boundary, if not ongoing

....detail0..*Reference (Resource)The event(s) being documented

.....reference0..1StringRelative, internal or absolute URL reference

.....display0..1StringText alternative for the resource

...encounter0..1Reference (careconnect-encounter-1)Context of the Composition

....reference1..1StringRelative URL reference

....display0..1StringText alternative for the resource

...section0..*BackboneElementComposition is broken into sections

....title0..1StringLabel for section

....code0..1CodeableConceptClassification of section (recommended)
Binding A code from the SNOMED Clinical Terminology UK coding system which represent the type of section. (http://fhir.nhs.net/ValueSet/section-type-snct-1)
Binding Strength Preferred

.....coding0..1CodingCode defined by a terminology system
Binding A code from the SNOMED Clinical Terminology UK coding system which represent the type of section. (http://fhir.nhs.net/ValueSet/section-type-snct-1)
Binding Strength Preferred

......system0..1UriIdentity of the terminology system
Fixed Value http://snomed.info/sct

......version0..1StringVersion of the system - if relevant

......code0..1CodeSymbol in syntax defined by the system

......display0..1StringRepresentation defined by the system

......userSelected0..1BooleanIf this coding was chosen directly by the user

.....text0..1StringPlain text representation of the concept

....text0..1NarrativeText summary of the section, for human interpretation

.....status1..1Codegenerated | extensions | additional | empty
Binding The status of a resource narrative (http://hl7.org/fhir/ValueSet/narrative-status)
Binding Strength Required

.....div1..1XhtmlLimited xhtml content

....mode0..1Codeworking | snapshot | changes
Binding The processing mode that applies to this section. (http://hl7.org/fhir/ValueSet/list-mode)
Binding Strength Required

....orderedBy0..1CodeableConceptOrder of section entries
Binding What order applies to the items in the entry. (http://hl7.org/fhir/ValueSet/list-order)
Binding Strength Preferred

.....coding0..*CodingCode defined by a terminology system

......system0..1UriIdentity of the terminology system

......version0..1StringVersion of the system - if relevant

......code0..1CodeSymbol in syntax defined by the system

......display0..1StringRepresentation defined by the system

......userSelected0..1BooleanIf this coding was chosen directly by the user

.....text0..1StringPlain text representation of the concept

....entry0..*Reference (Resource)A reference to data that supports this section

....emptyReason0..1CodeableConceptWhy the section is empty
Binding If a section is empty, why it is empty. (http://hl7.org/fhir/ValueSet/list-empty-reason)
Binding Strength Preferred

.....coding0..*CodingCode defined by a terminology system

......system0..1UriIdentity of the terminology system

......version0..1StringVersion of the system - if relevant

......code0..1CodeSymbol in syntax defined by the system

......display0..1StringRepresentation defined by the system

......userSelected0..1BooleanIf this coding was chosen directly by the user

.....text0..1StringPlain text representation of the concept

....section0..*see sectionNested Section

Name Type Description & Constraints
. . Extension-COFE-Data-Enterer-1 Extension Extension for CDA data enterer (transcriptionist).
. . Extension-COFE-Informant-1 Extension Extension for CDA informant.
. . Extension-COFE-Information-Recipient-1 Extension Extension for CDA information recipient.
. . Extension-COFE-Participant-1 Extension Extension for CDA participant.
. . Extension-COFE-Performer-1 Extension Extension for CDA performer.
. . Extension-COFE-Authorization-1 Extension Extension for CDA authorization.
. . Extension-COFE-Care-Setting-Type-1 Extension Extension for a Care Setting.
Path Name Binding Strength ValueSet
.Composition.type type Preferred http://fhir.nhs.net/ValueSet/document-type-1
.Composition.type.coding coding Preferred http://fhir.nhs.net/ValueSet/document-type-1
.Composition.type.coding.code code Preferred http://fhir.nhs.net/ValueSet/document-type-1
.Composition.confidentiality confidentiality Required http://hl7.org/fhir/ValueSet/v3-Confidentiality
.Composition.event.code code Preferred http://snomed.info/sct
.Composition.event.code.coding coding Preferred http://snomed.info/sct
.Composition.section.code code Preferred http://fhir.nhs.net/ValueSet/section-type-snct-1
.Composition.section.code.coding coding Preferred http://fhir.nhs.net/ValueSet/section-type-snct-1

COFE-Composition-1

Examples Description XML File
COFE-Composition-1-Example-1 COFE Composition