FHIR Implementation Guide for ABDM
3.1.0 - active
FHIR Implementation Guide for ABDM
3.1.0 - active
FHIR Implementation Guide for ABDM - Local Development build (v3.1.0). See the Directory of published versions
| Official URL: https://nrces.in/ndhm/fhir/r4/StructureDefinition/PrescriptionRecord | Version: 3.1.0 | |||
| Draft as of 2020-08-17 | Computable Name: PrescriptionRecord | |||
The Clinical Artifact represents the medication advice to the patient in compliance with the Pharmacy Council of India (PCI) guidelines, which can be shared across the health ecosystem.
This profile sets minimum expectations for the PrescriptionRecord to record, search, and fetch the details of medications prescribed to a patient in a particular encounter. It identifies the mandatory core elements, vocabularies and value sets which SHALL be present in the Composition resource when using this profile.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |
  status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
 type | S | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") |
 coding | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record | |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | |
 display | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | |
| text | S | 0..1 | string | Plain text representation of the concept |
 subject | S | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| encounter | 0..1 | Reference(Encounter) | Context of the Composition | |
| date | S | 1..1 | dateTime | Composition editing time |
| author | S | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| title | S | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
 section | S | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests |
 code | ||||
| coding | S | 0..* | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | |
| text | S | 0..1 | string | Plain text representation of the concept |
 Slices for entry | S | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
  entry:MedicationRequest | S | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
  reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
 type | 1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: MedicationRequest | |
 entry:Binary | 0..1 | Reference(Binary) | A reference to data that supports this section | |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| type | 1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: Binary | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
 type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| coding | Σ | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date | SΣ | 1..1 | dateTime | Composition editing time |
| author | SΣ | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| title | SΣ | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| section | SC | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| coding | SΣ | 0..* | Coding | Code defined by a terminology system |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| Slices for entry | SC | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
| entry:MedicationRequest | SC | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: MedicationRequest |
| entry:Binary | C | 0..1 | Reference(Binary) | A reference to data that supports this section |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Binary |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | FHIRDocumentTypeCodes |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.entry:MedicationRequest.type | extensible | Fixed Value: MedicationRequest |
| Composition.section.entry:Binary.type | extensible | Fixed Value: Binary |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
 extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | ||||
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | Composition editing time | ||||
| author | SΣ | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| title | SΣ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
 target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section | SC | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | SΣ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | ||||
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type | ||||
| entry:MedicationRequest | SC | 0..* | Reference(MedicationRequest) | A reference to data that supports this section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: MedicationRequest | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| entry:Binary | C | 0..1 | Reference(Binary) | A reference to data that supports this section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Binary | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | FHIRDocumentTypeCodes | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.author.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.entry:MedicationRequest.type | extensible | Fixed Value: MedicationRequest | ||||
| Composition.section.entry:Binary.type | extensible | Fixed Value: Binary | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 8 elements (6 nested mandatory elements)
Must-Support: 13 elements
Fixed Value: 8 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Composition
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |
| status | S | 1..1 | code | preliminary | final | amended | entered-in-error |
| type | S | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") |
| coding | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record | |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | |
| text | S | 0..1 | string | Plain text representation of the concept |
| subject | S | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| encounter | 0..1 | Reference(Encounter) | Context of the Composition | |
| date | S | 1..1 | dateTime | Composition editing time |
| author | S | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| title | S | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |
| custodian | 0..1 | Reference(Organization) | Organization which maintains the composition | |
| section | S | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests |
| code | ||||
| coding | S | 0..* | Coding | Code defined by a terminology system |
| system | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | |
| code | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | |
| display | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | |
| text | S | 0..1 | string | Plain text representation of the concept |
| Slices for entry | S | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
| entry:MedicationRequest | S | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| type | 1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: MedicationRequest | |
| entry:Binary | 0..1 | Reference(Binary) | A reference to data that supports this section | |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| type | 1..1 | uri | Type the reference refers to (e.g. "Patient") Fixed Value: Binary | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. |
| type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. |
| coding | Σ | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition |
| date | SΣ | 1..1 | dateTime | Composition editing time |
| author | SΣ | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| title | SΣ | 1..1 | string | Human Readable name/title |
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition |
| section | SC | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |
| coding | SΣ | 0..* | Coding | Code defined by a terminology system |
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 |
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record |
| text | SΣ | 0..1 | string | Plain text representation of the concept |
| Slices for entry | SC | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type |
| entry:MedicationRequest | SC | 0..* | Reference(MedicationRequest) | A reference to data that supports this section |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: MedicationRequest |
| entry:Binary | C | 0..1 | Reference(Binary) | A reference to data that supports this section |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Binary |
| Documentation for this format | ||||
| Path | Conformance | ValueSet / Code |
| Composition.status | required | CompositionStatus |
| Composition.type | preferred | FHIRDocumentTypeCodes |
| Composition.attester.mode | required | CompositionAttestationMode |
| Composition.section.code | example | DocumentSectionCodes |
| Composition.section.entry:MedicationRequest.type | extensible | Fixed Value: MedicationRequest |
| Composition.section.entry:Binary.type | extensible | Fixed Value: Binary |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| dom-2 | error | Composition | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | Composition | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | Composition | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | Composition | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation / A set of resources composed to define the prescription record. | |||||
| id | Σ | 0..1 | id | Logical id of this artifact | ||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier | Σ | 0..1 | Identifier | Version-independent identifier for the Composition | ||||
| status | ?!SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. | ||||
| type | SΣ | 1..1 | CodeableConcept | Kind of composition ("Prescription record ") Binding: FHIRDocumentTypeCodes (preferred): Type of a composition. | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | Σ | 1..1 | Coding | Code defined by a terminology system/ Code defined by SNOMED CT for Prescription record | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | ||||
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| category | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject | SΣ | 1..1 | Reference(Patient) | Who and/or what the composition/Prescription record is about | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | Context of the Composition | ||||
| date | SΣ | 1..1 | dateTime | Composition editing time | ||||
| author | SΣ | 1..* | Reference(Practitioner | Organization | PractitionerRole | Patient | Device | RelatedPerson) | Who and/or what authored the composition/Presciption record | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| title | SΣ | 1..1 | string | Human Readable name/title | ||||
| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition. | ||||
| attester | S | 0..* | BackboneElement | Attests to accuracy of composition | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| mode | 1..1 | code | personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition. | |||||
| time | 0..1 | dateTime | When the composition was attested | |||||
| party | 0..1 | Reference(RelatedPerson | PractitionerRole | Practitioner | Patient | Organization) | Who attested the composition | |||||
| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | ||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target[x] | 1..1 | Target of the relationship | ||||||
| targetIdentifier | Identifier | |||||||
| targetReference | Reference(Composition) | |||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | ||||
| period | Σ | 0..1 | Period | The period covered by the documentation | ||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | ||||
| section | SC | 1..1 | BackboneElement | Composition is broken into sections / Prescription record contains single section to define the relevant medication requests | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| title | 0..1 | string | Label for section (e.g. for ToC) | |||||
| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding | SΣ | 0..* | Coding | Code defined by a terminology system | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://snomed.info/sct | ||||
| version | Σ | 0..1 | string | Version of the system - if relevant | ||||
| code | Σ | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 440545006 | ||||
| display | Σ | 1..1 | string | Representation defined by the system Fixed Value: Prescription record | ||||
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
| text | SΣ | 0..1 | string | Plain text representation of the concept | ||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | |||||
| focus | 0..1 | Reference(Resource) | Who/what the section is about, when it is not about the subject of composition | |||||
| text | C | 0..1 | Narrative | Text summary of the section, for human interpretation | ||||
| mode | 0..1 | code | working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section. | |||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry. | |||||
| Slices for entry | SC | 1..* | Reference(MedicationRequest | Binary) | A reference to data that supports this section Slice: Unordered, Closed by value:type | ||||
| entry:MedicationRequest | SC | 0..* | Reference(MedicationRequest) | A reference to data that supports this section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: MedicationRequest | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| entry:Binary | C | 0..1 | Reference(Binary) | A reference to data that supports this section | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Fixed Value: Binary | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty. | ||||
| section | C | 0..* | See section (Composition) | Nested Section | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | ||||
| Composition.language | preferred | CommonLanguages
| ||||
| Composition.status | required | CompositionStatus | ||||
| Composition.type | preferred | FHIRDocumentTypeCodes | ||||
| Composition.category | example | DocumentClassValueSet | ||||
| Composition.subject.type | extensible | ResourceType | ||||
| Composition.author.type | extensible | ResourceType | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassification | ||||
| Composition.attester.mode | required | CompositionAttestationMode | ||||
| Composition.relatesTo.code | required | DocumentRelationshipType | ||||
| Composition.event.code | example | ActCode | ||||
| Composition.section.code | example | DocumentSectionCodes | ||||
| Composition.section.mode | required | ListMode | ||||
| Composition.section.orderedBy | preferred | ListOrderCodes | ||||
| Composition.section.entry:MedicationRequest.type | extensible | Fixed Value: MedicationRequest | ||||
| Composition.section.entry:Binary.type | extensible | Fixed Value: Binary | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasons |
| Id | Grade | Path(s) | Details | Requirements |
| cmp-1 | error | Composition.section | A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists() | |
| cmp-2 | error | Composition.section | A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from Composition
Summary
Mandatory: 8 elements (6 nested mandatory elements)
Must-Support: 13 elements
Fixed Value: 8 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron