Composition elements
id
Data type: Id |
Optionality: Mandatory | Cardinality: 1..1 |
The logical identifier of the Composition resource
meta.profile
Data type: uri |
Optionality: Mandatory | Cardinality: 1..1 |
The Composition profile URL.
identifier
Data type: Identifier |
Optionality: Mandatroy | Cardinality: 1..* |
This is for business identifiers.
This is sliced to include a cross care setting identifier which MUST be populated. The codeSystem for this identifier is https://fhir.nhs.uk/Id/cross-care-setting-identifier.
Is there any cross domain identifier for Composition ? Or should there be other than by convention ?
status
Data type: code |
Optionality: Mandatroy | Cardinality: 1..1 |
Fixed values of final
type
Data type: code |
Optionality: Mandatory | Cardinality: 1..1 |
| Use fixed value code of **325851000000107 | Consultation encounter type (record artifact) | ** to identify the Composition type as a GP Connect structured consultation rather than any other document type. |
subject
Data type: Reference(Patient) |
Optionality: Mandatory | Cardinality: 1..1 |
Reference to the Patient resource for the patient whose patient record contains a consultation represented by this Composition resource.
encounter
Data type: Reference(Encounter) |
Optionality: Mandatory | Cardinality: 1..1 |
Mandatory reference to the Encounter resource providing the context for the Consultation (Date/Doctor/Place ….)
date
Data type: dateTime |
Optionality: Mandatory | Cardinality: 1..1 |
The system rather than clinical date time for when the consultation was last edited i.e. the date time the consultation was last modified on the source system.
author
Data type: Reference(Practitioner) |
Optionality: Mandatory | Cardinality: 1..1 |
The system (audit trail) user attributed to the authoring or modification the consultation.
title
Data type: string |
Optionality: Mandatory | Cardinality: 1..1 |
The type or name of the consultation as it appears to users of the source system. Duplicates Encounter.type
confidentiality
Not used in GP Connect
attester
Not used in GP Connect
custodian
Not used in GP Connect
relatesTo
Not used in GP Connect
event
Not used in GP Connect
Top level Section
Composition.section
Data type: string |
Optionality: Mandatory | Cardinality: 1..* |
Represents the top level topic/problem structure of a consultation or in the case of flat ‘unstructured’ consultations is used to group the resources representing record entries within the source consultation.
extension.valueReference
TO DO add extension to allow resolution of problem link to composition section - will be back reference to problem id … nb this is in the 1st instance intended to be used to resolve the problem reference e.g. problem references composition and consumer must then look for the section with the id that corresponds to the problem to make the linkage c
But also is this link needed - if standardisation means expanding linkages to child resources?
Composition.section.title
Data type: string |
Optionality: Optional | Cardinality: 0..1 |
Where a consultation section is titled in the source system, carries the title of the consultation as displayed to users. This may be a user entered value or where consultation sections are driven by problems obtained from the term/rubric of the problem linked to the consultation section.
Will not be present where a consultation section is untitled on the source system or where the Consultation.section is conveying unstructured (flat) consultation structure.
Composition.section.code
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
| Use fixed value of **25851000000105 | Topic (EHR) (record artifact) | ** |
Composition.section.text
TBD - Either not used in GP Connect. Any textual rendering of the Composition content can be generated by a receiving system from the structured set of resources referenced within the top level Composition.section or subsection (Composition.section.section) OR it is used and a simplified XHTML digest of the consultation section is always geneerated by convention.
Composition.section.mode
Data type: code |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of snapshot. Explicitly identified that each composition is a snapshot of the current consultation on the source system rather than an incremental update.
Composition.section.orderedBy
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of system from http://hl7.org/fhir/list-order vocabulary.
By convention the order enries should appear is the default order subsections or entries are displayed by the native system at source.
Composition.section.entry
Data type: Reference(Observation | AllergyIntolerance | MedicationRequest | ReferralRequest ... TO DO Constrain to finalised set of GP Connect resources) |
Optionality: Optional | Cardinality: 0..* |
A top level section will have entries if it is used to express unstructured (flat) consultation content. Otherwise no entry references will be present.
TBD …. handling of TPP problem to … section to linkages possible extension of section for id
Composition.section.emptyReason
Not used in GP Connect.
Where a system allows ‘empty’ sections to be recorded these should be suppressed in any query results in the same way that ‘empty’ consultations are suppressed.
Composition.section.section
Data type: section |
Optionality: Optional | Cardinality: 0..* |
Each child .section of Composition.section is used to represent a sub-heading within a topic level of the source consultation. These are often referred to as SOAP headings but the set of headings/groupings supported by source system consultations is more diverse than the original SOAP classification.
The subssection level is optional because a top level Composition.section may be used to contain unstructured (flat) record entries.
A top level Composition.section must not be used to represent both unstructured (flat) record contentent and a structured consultation (SOAP Heading structured consultation), therefore Composition.section.entry and Composition.section.section attributes are mutually exclusive.
Structured Consultation Content - SOAP Headings
Nested Composition.section.section attributes are used to represent structured consultation content organised around the SOAP heading model.
Composition.section.section.title
Data type: string |
Optionality: Mandatory | Cardinality: 1..1 |
Provides the title text displayed for the Consultation sub-heading on the source system. Mandatory because all headings are named/titled.
Composition.section.section.code
Not used
Due to the diverse range of headings in use with limited mapping to available vocabularies and also considering the limited value to consumers in coding these it is better to express the heading title as .title rather than attempt a coding
Composition.section.section.text
Not used in GP Connect. Any textual rendering of the Composition content can be generated by a receiving system from the structured set of resources referenced within each section.
TBD - demand on outcpome of narrative discussion
Composition.section.section.mode
Data type: code |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of snapshot. Explicitly identifies that each composition section and subsection is a snapshot of the current consultation on the source system rather than an incremental update.
Composition.section.section.orderedBy
Data type: CodeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Fixed value of system from http://hl7.org/fhir/list-order vocabulary.
By convention the order used is the default order subsections or entries are displayed by the native system at source.
Composition.section.section.entry
Data type: Reference(Observation | AllergyIntolerance | MedicationRequest | ReferralRequest ... TO DO Constrain to finalised set of GP Connect resources) |
Optionality: Mandatory | Cardinality: 1..* |
Each entry is a reference to the Resoirce representing the source record entry within the heading section.
Composition.section.emptyReason
Not used in GP Connect.
Where a system allows ‘empty’ sub-heading sections to be recorded these should be suppressed in any query results in the same way that ‘empty’ consultations are suppressed.
Composition.section.section.section
Not used in GP Connect. There is no further section structure under the SOAP heading structure.
