FHIR Implementation Guide for NDHM CI Build v2.0
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NDHM (R4), Published and maintained by NRCeS for NHA.
This version is based on the NDHM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-HealthDocumentRecord

This profile sets minimum expectations for the HealthDocumentRecord to record, search, and fetch the details of the health document of a patient. The record supports uploading and sharing of the scanned document that includes historical documents also. It identifies the mandatory core elements, vocabularies, and value sets which SHALL be present in the Composition resource when using this profile.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://nrces.in/ndhm/fhir/r4/StructureDefinition/HealthDocumentRecord

This profile builds on Composition

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition ("Prescription record ")
.... coding 1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
..... display 1..1stringRepresentation defined by the system
Fixed Value: Record artifact
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
...... display 1..1stringRepresentation defined by the system
Fixed Value: Record artifact
..... text S0..1stringPlain text representation of the concept
.... entry S1..*Reference(DocumentReference)A reference to data that supports this section
..... reference 1..1stringLiteral reference, Relative, internal or absolute URL

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣI1..1CodeableConceptKind of composition ("Prescription record ")
Binding: FHIRDocumentTypeCodes (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
..... display ΣI1..1stringRepresentation defined by the system
Fixed Value: Record artifact
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text SΣI0..1stringPlain text representation of the concept
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣI1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... encounter ΣI0..1Reference(Encounter)Context of the Composition
... date SΣI1..1dateTimeComposition editing time
... author SΣI1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... title SΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required)
... attester SI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodThe period covered by the documentation
.... detail ΣI0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version ΣI0..1stringVersion of the system - if relevant
...... code ΣI1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
...... display ΣI1..1stringRepresentation defined by the system
Fixed Value: Record artifact
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text SΣI0..1stringPlain text representation of the concept
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
.... entry SI1..*Reference(DocumentReference)A reference to data that supports this section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
.... section I0..*See sectionNested Section

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition 0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... status S1..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of composition ("Prescription record ")
.... coding 1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
..... display 1..1stringRepresentation defined by the system
Fixed Value: Record artifact
.... text S0..1stringPlain text representation of the concept
... subject S1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... encounter 0..1Reference(Encounter)Context of the Composition
... date S1..1dateTimeComposition editing time
... author S1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... reference 1..1stringLiteral reference, Relative, internal or absolute URL
... title S1..1stringHuman Readable name/title
... attester S0..*BackboneElementAttests to accuracy of composition
.... party 0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian 0..1Reference(Organization)Organization which maintains the composition
... section S1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... code
..... coding S0..*CodingCode defined by a terminology system
...... system 0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... code 1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
...... display 1..1stringRepresentation defined by the system
Fixed Value: Record artifact
..... text S0..1stringPlain text representation of the concept
.... entry S1..*Reference(DocumentReference)A reference to data that supports this section
..... reference 1..1stringLiteral reference, Relative, internal or absolute URL

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Composition I0..*CompositionA set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record.
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... identifier ΣI0..1IdentifierVersion-independent identifier for the Composition
... status ?!SΣI1..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣI1..1CodeableConceptKind of composition ("Prescription record ")
Binding: FHIRDocumentTypeCodes (preferred)
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding ΣI1..1CodingCode defined by a terminology system/ Code defined by SNOMED CT for Prescription record
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version ΣI0..1stringVersion of the system - if relevant
..... code ΣI1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
..... display ΣI1..1stringRepresentation defined by the system
Fixed Value: Record artifact
..... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
.... text SΣI0..1stringPlain text representation of the concept
... category ΣI0..*CodeableConceptCategorization of Composition
Binding: DocumentClassValueSet (example)
... subject SΣI1..1Reference(Patient)Who and/or what the composition/Prescription record is about
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... encounter ΣI0..1Reference(Encounter)Context of the Composition
... date SΣI1..1dateTimeComposition editing time
... author SΣI1..*Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson)Who and/or what authored the composition/Presciption record
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
.... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
.... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
.... display ΣI0..1stringText alternative for the resource
... title SΣI1..1stringHuman Readable name/title
... confidentiality ΣI0..1codeAs defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required)
... attester SI0..*BackboneElementAttests to accuracy of composition
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... mode I1..1codepersonal | professional | legal | official
Binding: CompositionAttestationMode (required)
.... time I0..1dateTimeWhen the composition was attested
.... party I0..1Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization)Who attested the composition
... custodian ΣI0..1Reference(Organization)Organization which maintains the composition
... relatesTo I0..*BackboneElementRelationships to other compositions/documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code I1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target[x] I1..1Target of the relationship
..... targetIdentifierIdentifier
..... targetReferenceReference(Composition)
... event ΣI0..*BackboneElementThe clinical service(s) being documented
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI0..*CodeableConceptCode(s) that apply to the event being documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodThe period covered by the documentation
.... detail ΣI0..*Reference(Resource)The event(s) being documented
... section SI1..1BackboneElementComposition is broken into sections / Prescription record contains single section to define the relevant medication requests
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... title I0..1stringLabel for section (e.g. for ToC)
.... code I0..1CodeableConceptClassification of section (recommended)
Binding: DocumentSectionCodes (example)
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding SΣI0..*CodingCode defined by a terminology system
...... id 0..1stringUnique id for inter-element referencing
...... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
...... system ΣI0..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
...... version ΣI0..1stringVersion of the system - if relevant
...... code ΣI1..1codeSymbol in syntax defined by the system
Fixed Value: 419891008
...... display ΣI1..1stringRepresentation defined by the system
Fixed Value: Record artifact
...... userSelected ΣI0..1booleanIf this coding was chosen directly by the user
..... text SΣI0..1stringPlain text representation of the concept
.... author I0..*Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)Who and/or what authored the section
.... focus I0..1Reference(Resource)Who/what the section is about, when it is not about the subject of composition
.... text I0..1NarrativeText summary of the section, for human interpretation
.... mode I0..1codeworking | snapshot | changes
Binding: ListMode (required)
.... orderedBy I0..1CodeableConceptOrder of section entries
Binding: ListOrderCodes (preferred)
.... entry SI1..*Reference(DocumentReference)A reference to data that supports this section
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣI1..1stringLiteral reference, Relative, internal or absolute URL
..... type ΣI0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible)
..... identifier ΣI0..1IdentifierLogical reference, when literal reference is not known
..... display ΣI0..1stringText alternative for the resource
.... emptyReason I0..1CodeableConceptWhy the section is empty
Binding: ListEmptyReasons (preferred)
.... section I0..*See sectionNested Section

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron