Nictiz FHIR NL STU3 Zib2017 - Local Development build (v1.3.15) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: gp-EncounterReport

The general practitioner encounter report is an S-O-A-P (Subjective, Objective, Assessment, Plan) structured report of a patient encounter. S-O-A-P is known as S-O-E-P (Subjectief, Objectief, Evaluatie, Plan) in Dutch. Each Composition.section corresponds with a letter from SOAP and may additionally be ICPC coded using the appropriate extension. If the encounter report relates to an episode of care then the association with EpisodeOfCare shall be in Composition.event.detail.

Usage:

• Examples for this Resource Profile: Composition/gp-encounterreport-01

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

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
type
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 67781-5
encounter		1..1	Reference(HCIM Encounter)	Context of the Composition
author		1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
title		1..1	string	Human Readable name/title
attester
party		0..1	Reference(nl-core-patient | nl-core-practitioner | nl-core-organization)	Who attested the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
custodian		0..1	Reference(nl-core-organization)	Organization which maintains the composition
section
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
code_icpc_1_nl		0..1	CodeableConcept	Extension URL: http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl
code		1..1	CodeableConcept	Classification of section (recommended) Binding: JournaalregelType (required)
text		1..1	Narrative	Text summary of the section, for human interpretation
entry		0..*	Reference(Resource)	A reference to data that supports this section
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.section.code	required	JournaalregelType http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000 from this IG

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition.
subject	Σ	1..1	Reference(Resource)	Who and/or what the composition is about
encounter	Σ	1..1	Reference(HCIM Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
title	Σ	1..1	string	Human Readable name/title
confidentiality	?!Σ	0..1	code	As defined by affinity domain Binding: ConfidentialityClassification (required): Codes specifying the level of confidentiality of the composition.
custodian	Σ	0..1	Reference(nl-core-organization)	Organization which maintains the composition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard
Composition.type	preferred	FHIR Document Type Codes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.confidentiality	required	ConfidentialityClassification http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-1	error	Composition	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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 : contained.where(('#'+id in %resource.descendants().reference).not()).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()

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
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: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
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	Logical identifier of composition (version-independent)
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	xml:id (or equivalent in JSON)
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://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 67781-5
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: FHIR Document Class Codes (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Resource)	Who and/or what the composition is about
encounter	Σ	1..1	Reference(HCIM Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
title	Σ	1..1	string	Human Readable name/title
confidentiality	?!Σ	0..1	code	As defined by affinity domain Binding: ConfidentialityClassification (required): Codes specifying the level of confidentiality of the composition.
attester	Σ	0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
mode	Σ	1..*	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time	Σ	0..1	dateTime	When the composition was attested
party	Σ	0..1	Reference(nl-core-patient | nl-core-practitioner | nl-core-organization)	Who attested the composition
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
custodian	Σ	0..1	Reference(nl-core-organization)	Organization which maintains the composition
relatesTo	Σ	0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]	Σ	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	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: 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	C	0..*	BackboneElement	Composition is broken into sections cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
code_icpc_1_nl		0..1	CodeableConcept	Extension URL: http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: JournaalregelType (required)
text	C	1..1	Narrative	Text summary of the section, for human interpretation
mode	?!Σ	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: List Order Codes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard
Composition.type	preferred	FHIR Document Type Codes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.class	example	FHIR Document Class Codes http://hl7.org/fhir/ValueSet/doc-classcodes from the FHIR Standard
Composition.confidentiality	required	ConfidentialityClassification http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type from the FHIR Standard
Composition.event.code	example	v3 Code System ActCode http://hl7.org/fhir/ValueSet/v3-ActCode from the FHIR Standard
Composition.section.code	required	JournaalregelType http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000 from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode from the FHIR Standard
Composition.section.orderedBy	preferred	List Order Codes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	List Empty Reasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must 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-1	error	Composition	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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 : contained.where(('#'+id in %resource.descendants().reference).not()).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()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (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: 1 element(2 nested mandatory elements)
Fixed: 2 elements

Structures

This structure refers to these other structures:

• HCIM Encounter (http://nictiz.nl/fhir/StructureDefinition/zib-Encounter)
• nl-core-practitioner (http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner)
• HCIM MedicalDevice Product (http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct)
• nl-core-patient (http://fhir.nl/fhir/StructureDefinition/nl-core-patient)
• nl-core-relatedperson (http://fhir.nl/fhir/StructureDefinition/nl-core-relatedperson)
• nl-core-organization (http://fhir.nl/fhir/StructureDefinition/nl-core-organization)

Extensions

This structure refers to these extensions:

• http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
• http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl

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
type
coding
system		0..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Fixed Value: 67781-5
encounter		1..1	Reference(HCIM Encounter)	Context of the Composition
author		1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
title		1..1	string	Human Readable name/title
attester
party		0..1	Reference(nl-core-patient | nl-core-practitioner | nl-core-organization)	Who attested the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
custodian		0..1	Reference(nl-core-organization)	Organization which maintains the composition
section
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
code_icpc_1_nl		0..1	CodeableConcept	Extension URL: http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl
code		1..1	CodeableConcept	Classification of section (recommended) Binding: JournaalregelType (required)
text		1..1	Narrative	Text summary of the section, for human interpretation
entry		0..*	Reference(Resource)	A reference to data that supports this section
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.section.code	required	JournaalregelType http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000 from this IG

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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition.
subject	Σ	1..1	Reference(Resource)	Who and/or what the composition is about
encounter	Σ	1..1	Reference(HCIM Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
title	Σ	1..1	string	Human Readable name/title
confidentiality	?!Σ	0..1	code	As defined by affinity domain Binding: ConfidentialityClassification (required): Codes specifying the level of confidentiality of the composition.
custodian	Σ	0..1	Reference(nl-core-organization)	Organization which maintains the composition
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard
Composition.type	preferred	FHIR Document Type Codes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.confidentiality	required	ConfidentialityClassification http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-1	error	Composition	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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 : contained.where(('#'+id in %resource.descendants().reference).not()).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()

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
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: Common Languages (extensible): A human language. Additional Bindings Purpose AllLanguages Max Binding
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	Logical identifier of composition (version-independent)
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: FHIR Document Type Codes (preferred): Type of a composition.
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	xml:id (or equivalent in JSON)
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://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system Fixed Value: 67781-5
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: FHIR Document Class Codes (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Resource)	Who and/or what the composition is about
encounter	Σ	1..1	Reference(HCIM Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(nl-core-practitioner | HCIM MedicalDevice Product | nl-core-patient | nl-core-relatedperson)	Who and/or what authored the composition
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
title	Σ	1..1	string	Human Readable name/title
confidentiality	?!Σ	0..1	code	As defined by affinity domain Binding: ConfidentialityClassification (required): Codes specifying the level of confidentiality of the composition.
attester	Σ	0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
mode	Σ	1..*	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time	Σ	0..1	dateTime	When the composition was attested
party	Σ	0..1	Reference(nl-core-patient | nl-core-practitioner | nl-core-organization)	Who attested the composition
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
practitionerRole		0..1	Reference(nl-core-practitionerrole)	Optional Extensions Element URL: http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
custodian	Σ	0..1	Reference(nl-core-organization)	Organization which maintains the composition
relatesTo	Σ	0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]	Σ	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	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: 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	C	0..*	BackboneElement	Composition is broken into sections cmp-1: A section must at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	xml:id (or equivalent in JSON)
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
code_icpc_1_nl		0..1	CodeableConcept	Extension URL: http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: JournaalregelType (required)
text	C	1..1	Narrative	Text summary of the section, for human interpretation
mode	?!Σ	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: List Order Codes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: List Empty Reasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	extensible	Common Languages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status from the FHIR Standard
Composition.type	preferred	FHIR Document Type Codes http://hl7.org/fhir/ValueSet/doc-typecodes from the FHIR Standard
Composition.class	example	FHIR Document Class Codes http://hl7.org/fhir/ValueSet/doc-classcodes from the FHIR Standard
Composition.confidentiality	required	ConfidentialityClassification http://hl7.org/fhir/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type from the FHIR Standard
Composition.event.code	example	v3 Code System ActCode http://hl7.org/fhir/ValueSet/v3-ActCode from the FHIR Standard
Composition.section.code	required	JournaalregelType http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.103.11.2--20111012000000 from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode from the FHIR Standard
Composition.section.orderedBy	preferred	List Order Codes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	List Empty Reasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must 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-1	error	Composition	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.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 : contained.where(('#'+id in %resource.descendants().reference).not()).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()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() | (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: 1 element(2 nested mandatory elements)
Fixed: 2 elements

Structures

This structure refers to these other structures:

• HCIM Encounter (http://nictiz.nl/fhir/StructureDefinition/zib-Encounter)
• nl-core-practitioner (http://fhir.nl/fhir/StructureDefinition/nl-core-practitioner)
• HCIM MedicalDevice Product (http://nictiz.nl/fhir/StructureDefinition/zib-MedicalDeviceProduct)
• nl-core-patient (http://fhir.nl/fhir/StructureDefinition/nl-core-patient)
• nl-core-relatedperson (http://fhir.nl/fhir/StructureDefinition/nl-core-relatedperson)
• nl-core-organization (http://fhir.nl/fhir/StructureDefinition/nl-core-organization)

Extensions

This structure refers to these extensions:

• http://nictiz.nl/fhir/StructureDefinition/practitionerrole-reference
• http://nictiz.nl/fhir/StructureDefinition/code-icpc-1-nl

Other representations of profile: CSV, Excel, Schematron