Composition resource implementation guidance
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Composition: Implementation Guidance
Usage
Used to represent a human-readable summary of the triage journey for a patient.
The sending EMS is responsible for making sure that all resources which inform the `Composition` are referenced in the `Composition`.
The 'Composition' resource should only be used by ERRs that cannot build a custom Encounter Report from the resources referenced in the List resource.
The human-readable summary will be carried in a Composition. The composition associated with an encounter is linked through the Composition.encounter. The Encounter resource does not contain a reference to the composition. There may be more than one Composition per Encounter, for example, where a CDS is managing multiple ServiceDefinition interactions with the EMS for the same patient at the same time.
PLEASE NOTE that resources referenced by the Composition resource MUST NOT be used to drive business processes as they may not be the complete list of resources for the triage journey. The complete list for the triage journey will be contained in the List resource.
Detailed implementation guidance for a Composition resource in the CDS context is given below:
| Name | Cardinality | Type | FHIR Documentation | CDS Implementation Guidance |
|---|---|---|---|---|
id |
0..1 |
id | Logical id of this artifact | |
meta |
0..1 |
Meta | Metadata about the resource | |
implicitRules |
0..1 |
uri | A set of rules under which this content was created | |
language |
0..1 |
code | Language of the resource content. Common Languages (Extensible but limited to All Languages) |
|
text |
0..1 |
Narrative | Text summary of the resource, for human interpretation | |
contained |
0..* |
Resource | Contained, inline Resources | This SHOULD NOT be populated |
extension |
0..* |
Extension | Additional Content defined by implementations | |
modifierExtension |
0..* |
Extension | Extensions that cannot be ignored | |
identifier |
0..1 |
Identifier | Logical identifier of composition (version-independent) | |
status |
1..1 |
code | preliminary | final | amended | entered-in-error CompositionStatus (Required) |
At the end of the encounter, this will normally be final. This may be amended after the end of the encounter. |
type |
1..1 |
CodeableConcept | Kind of composition (LOINC if possible) FHIR Document Type Codes (Preferred) |
This MUST be populated with Snomed Code 371531000 |Report of clinical encounter (record artifact). |
class |
0..1 |
CodeableConcept | Categorization of Composition FHIR Document Class Codes (Example) |
This MUST NOT be populated |
subject |
1..1 |
Reference(Any) | Who and/or what the composition is about | This MUST be a reference to the Patient resource |
encounter |
0..1 |
Reference(Encounter) | Context of the Composition | This MUST be a reference to the current Encounter resource |
date |
1..1 |
dateTime | Composition editing time | This will be the date/time at the end of the triage journey |
author |
1..* |
Reference(Practitioner | Device | Patient | RelatedPerson) | Who and/or what authored the composition | This MUST be a reference to a Device resource, representing the EMS which is responsible for the encounter |
title |
1..1 |
string | Human Readable name/title | |
confidentiality |
0..1 |
code | As defined by affinity domain ConfidentialityClassification (Required) |
This will be determined by the EMS, and usually hold the value Normal
|
attester |
0..* |
BackboneElement | Attests to accuracy of composition | Should only be present if the composition has been presented to a user for attestation of completeness |
mode |
1..* |
code | personal | professional | legal | official CompositionAttestationMode (Required) |
|
time |
0..1 |
dateTime | When the composition was attested | |
party |
0..1 |
Reference(Patient | Practitioner | Organization) | Who attested the composition | |
custodian |
0..1 |
Reference(Organization) | Organization which maintains the composition | A reference to the Organisation that is responsible for the EMS |
relatesTo |
0..* |
BackboneElement | Relationships to other compositions/documents | This should be populated when an encounter is modified after completion. In this case, new information will be linked to the Encounter, so a new Composition will be needed, which will replace the previous Composition. The relationship of replacement is captured here |
code |
1..1 |
code | replaces | transforms | signs | appends DocumentRelationshipType (Required) |
Where populated, this MUST be replaces |
target[x] |
1..1 |
Target of the relationship | The Composition generated as a result of the encounter information before modification | |
targetIdentifier |
Identifier | |||
targetReference |
Reference(Composition) | |||
event |
0..* |
BackboneElement | The clinical service(s) being documented | This MUST NOT be populated |
section |
0..* |
BackboneElement | Composition is broken into sections + A section must at least one of text, entries, or sub-sections + A section can only have an emptyReason if it is empty |
It is recommended that each $evaluate interaction is documented in a separate section. This will document the Questionnaire & QuestionnaireResponse resources for that interaction, as well as the assertions generated during that interaction, and any CarePlans presented. In addition, if interim results are presented, these should be included in each interaction. The result of the interaction will also be presented as a separate section. |
title |
0..1 |
string | Label for section (e.g. for ToC) | This can be 'Result' or similar for the final section. |
code |
0..1 |
CodeableConcept | Classification of section (recommended) Document Section Codes (Example) |
|
text |
0..1 |
Narrative | Text summary of the section, for human interpretation | |
mode |
0..1 |
code | working | snapshot | changes ListMode (Required) |
|
orderedBy |
0..1 |
CodeableConcept | Order of section entries List Order Codes (Preferred) |
The sections should be presented in date/time order of the patient journey |
entry |
0..* |
Reference(Any) | A reference to data that supports this section | |
emptyReason |
0..1 |
CodeableConcept | Why the section is empty List Empty Reasons (Preferred) |
|
section |
0..* |
see section | Nested Section |
