HL7 Europe Laboratory Report
0.1.0-ballot - ballot 150

This page is part of the HL7 Europe Laboratory Report (v0.1.0-ballot: STU 1 Ballot 1) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: CompositionLabReportEu - Detailed Descriptions

Page standards status: Draft Maturity Level: 1

Definitions for the Composition-eu-lab resource profile.

Guidance on how to interpret the contents of this table can be found here

0. Composition
Definition

Laboratory Report composition.

ShortLaboratory Report composition
2. Composition.text
ShortNarrative text
4. Composition.extension:basedOn-order-or-requisition
Slice NamebasedOn-order-or-requisition
Control0..*
TypeExtension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest))
6. Composition.extension:basedOn-order-or-requisition.value[x]
[x] NoteSee Choice of Data Types for further information about how to use [x]
SlicingThis element introduces a set of slices on Composition.extension.value[x]. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • type @ $this
8. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference
Slice NamevalueReference
Control0..1
TypeReference(ServiceRequest: Laboratory Order)
[x] NoteSee Choice of Data Types for further information about how to use [x]
10. Composition.extension:information-recipient
Slice Nameinformation-recipient
Control0..*
TypeExtension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization))
12. Composition.identifier
Definition

Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions

ShortReport identifier
Comments

Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists

NoteThis is a business identifier, not a resource identifier (see discussion)
14. Composition.status
ShortStatus of the Report
Comments

DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping

16. Composition.type
Definition

Specifies that it refers to a Laboratory Report

ShortType of (Laboratory) Report
Comments

At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal

BindingThe codes SHOULD be taken from Laboratory Report Types
TypeCodeableConcept(Codeable Concept (IPS))
18. Composition.category
Definition

A code that classifies this laboratory report.

ShortReport Category
Comments

DiagnosticReport.category and Composition.category shall be aligned

TypeCodeableConcept(Codeable Concept (IPS))
SlicingThis element introduces a set of slices on Composition.category. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
20. Composition.category:studyType
Slice NamestudyType
Control0..*
BindingThe codes SHALL be taken from Laboratory Study Types
22. Composition.category:specialty
Slice Namespecialty
Control0..*
BindingThe codes SHALL be taken from Laboratory Specialty
24. Composition.subject
Definition

Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

ShortWho and/or what this report is about
Comments

DiagnosticReport and Composition SHALL have the same subject

Control1..?
TypeReference(Patient: Person, Patient: Animal, Group, Location, Device)
26. Composition.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.

ShortThe healthcare event which this Laboratory Report is about (when test ordered).
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

28. Composition.author
Definition

Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in.

ShortWho and/or what authored the Laboratory Report
Comments

If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author.

30. Composition.title
Definition

Official human-readable label for the composition.

ShortLaboratory Report
32. Composition.attester
ShortAttests the report accuracy
34. Composition.attester.mode
ShortThe type of attestation
36. Composition.attester.time
ShortWhen the report was attested by the party
38. Composition.attester.party
ShortWho attested the report
Comments

For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson

40. Composition.event
ShortThe laboratory service(s) being documented
42. Composition.event.code
ShortCode(s) that apply to the laboratory service(s) being documented
44. Composition.event.period
ShortPeriod of time covered by the documentation
46. Composition.event.detail
ShortThe laboratory service(s) being documented
48. Composition.section
Definition

The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format.

Control1..?
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • exists @ $this.section
  • exists @ $this.entry
50. Composition.section.title
Control1..?
52. Composition.section.code
Control1..?
TypeCodeableConcept(Codeable Concept (IPS))
54. Composition.section:lab-no-subsections
Slice Namelab-no-subsections
Definition

Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed.

ShortVariant 1: EU Laboratory Report section with entries and no sub-sections
Control0..*
56. Composition.section:lab-no-subsections.code
BindingThe codes SHOULD be taken from Laboratory Study Types
58. Composition.section:lab-no-subsections.text
ShortText summary of the section, for human interpretation.
60. Composition.section:lab-no-subsections.entry
Control1..?
TypeReference(Observation Results: laboratory)
62. Composition.section:lab-no-subsections.section
Control0..0
64. Composition.section:lab-subsections
Slice Namelab-subsections
Definition

Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry.

ShortVariant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item
Control0..*
66. Composition.section:lab-subsections.code
BindingThe codes SHOULD be taken from Laboratory Study Types
68. Composition.section:lab-subsections.text
Control0..0
70. Composition.section:lab-subsections.entry
Control0..0
72. Composition.section:lab-subsections.section
Control1..?
TypeBackboneElement
74. Composition.section:lab-subsections.section.title
Control1..?
76. Composition.section:lab-subsections.section.code
Control1..?
BindingThe codes SHOULD be taken from Laboratory Study Types
TypeCodeableConcept(Codeable Concept (IPS))
78. Composition.section:lab-subsections.section.text
ShortText summary of the section, for human interpretation.
80. Composition.section:lab-subsections.section.entry
Control1..?
TypeReference(Observation Results: laboratory)
82. Composition.section:lab-subsections.section.section
Control0..0
84. Composition.section:annotations
Slice Nameannotations
Definition

Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc.

ShortAnnotation comment
Control0..*
86. Composition.section:annotations.code
Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;48767-8&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
88. Composition.section:annotations.text
Control1..?
90. Composition.section:annotations.entry
Control0..0
92. Composition.section:annotations.section
Control0..0

Guidance on how to interpret the contents of this table can be found here

0. Composition
Definition

Laboratory Report composition.

A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.


A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).

ShortLaboratory Report compositionA set of resources composed into a single coherent clinical statement with clinical attestation
Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Composition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
4. Composition.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortNarrative textText summary of the resource, for human interpretation
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Composition.extension:versionNumber
Slice NameversionNumber
Definition

Version specific identifier for the composition, assigned when each version is created/updated.

ShortVersion-specific identifier for composition
Comments

While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(versionNumber) (Extension Type: string)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
8. Composition.extension:basedOn-order-or-requisition
Slice NamebasedOn-order-or-requisition
Definition

This extension provides a link to the order [(Reference(ServiceRequest)] or requisition [ServiceRequest.requisition (i.e., 'Request.groupIdentifier')] that this report document is based on and fulfills.

ShortDocument Based On Order
Control0..*
TypeExtension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest))
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
10. Composition.extension:basedOn-order-or-requisition.extension
Definition

An Extension


May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortExtensionAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..0*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Composition.extension.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
12. Composition.extension:basedOn-order-or-requisition.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Shortidentifies the meaning of the extension
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Control1..1
Typeuri
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
Fixed Valuehttp://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition
14. Composition.extension:basedOn-order-or-requisition.value[x]
Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

ShortValue of extension
Control0..1
TypeReference(ServiceRequest), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.extension.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • type @ $this
16. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference
Slice NamevalueReference
Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

ShortValue of extension
Control0..1
TypeReference(ServiceRequest: Laboratory Order), date, Meta, Address, Attachment, integer, Count, DataRequirement, Dosage, uuid, Identifier, Coding, SampledData, id, positiveInt, Distance, Period, Duration, canonical, Range, RelatedArtifact, base64Binary, UsageContext, Timing, decimal, CodeableConcept, ParameterDefinition, dateTime, code, string, Contributor, oid, instant, ContactPoint, HumanName, Money, markdown, Ratio, Age, TriggerDefinition, Quantity, uri, url, Annotation, ContactDetail, boolean, Expression, Signature, unsignedInt, time
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
18. Composition.extension:information-recipient
Slice Nameinformation-recipient
Definition

This extension applies to the Composition resource and is used to represent an intended recipient of the composition.

ShortInformation recipient
Control0..*
TypeExtension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization))
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
20. Composition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
22. Composition.identifier
Definition

Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions


A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time.

ShortReport identifierVersion-independent identifier for the Composition
Comments

Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists


Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
24. Composition.status
Definition

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

ShortStatus of the Reportpreliminary | final | amended | entered-in-error
Comments

DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping


If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements.

Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.

Control1..1
BindingThe codes SHALL be taken from CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1

The workflow/clinical status of the composition.

Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
26. Composition.type
Definition

Specifies that it refers to a Laboratory Report


Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.

ShortType of (Laboratory) ReportKind of composition (LOINC if possible)
Comments

At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal


For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.

Control1..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from Laboratory Report Typeshttp://hl7.org/fhir/ValueSet/doc-typecodes
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Key metadata element describing the composition, used in searching/filtering.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
28. Composition.category
Definition

A code that classifies this laboratory report.


A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortReport CategoryCategorization of Composition
Comments

DiagnosticReport.category and Composition.category shall be aligned


This is a metadata field from XDS/MHD.

Control0..*
BindingFor example codes, see DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes

High-level kind of a clinical document at a macro level.

TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.category. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
30. Composition.category:studyType
Slice NamestudyType
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortCategorization of Composition
Comments

This is a metadata field from XDS/MHD.

Control0..*
BindingThe codes SHALL be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/document-classcodes
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
32. Composition.category:specialty
Slice Namespecialty
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortCategorization of Composition
Comments

This is a metadata field from XDS/MHD.

Control0..*
BindingThe codes SHALL be taken from For example codes, see Laboratory Specialtyhttp://hl7.org/fhir/ValueSet/document-classcodes
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
34. Composition.subject
Definition

Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).


Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

ShortWho and/or what this report is aboutWho and/or what the composition is about
Comments

DiagnosticReport and Composition SHALL have the same subject


For clinical documents, this is usually the patient.

Control10..1
TypeReference(Patient: Person, Patient: Animal, Group, Location, Device, Resource)
Is Modifierfalse
Summarytrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Composition.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.


Describes the clinical encounter or type of care this documentation is associated with.

ShortThe healthcare event which this Laboratory Report is about (when test ordered).Context of the Composition
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

DiagnosticReport and Composition SHALL have the same encounter.

Control0..1
TypeReference(Encounter)
Is Modifierfalse
Summarytrue
Requirements

Provides context for the composition and supports searching.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Composition.date
Definition

The composition editing time, when the composition was last logically changed by the author.

ShortComposition editing time
Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.


dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Composition.author
Definition

Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in.


Identifies who is responsible for the information in the composition, not necessarily who typed it in.

ShortWho and/or what authored the Laboratory ReportWho and/or what authored the composition
Comments

If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author.

Control1..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summarytrue
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
42. Composition.title
Definition

Official human-readable label for the composition.

For this document should be "Laboratory Report" or any equivalent translation


Official human-readable label for the composition.

ShortLaboratory ReportHuman Readable name/title
Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Composition.attester
Definition

A participant who has attested to the accuracy of the composition/document.

ShortAttests the report accuracyAttests to accuracy of composition
Comments

Only list each attester once.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Identifies responsibility for the accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Composition.attester.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
48. Composition.attester.mode
Definition

The type of attestation the authenticator offers.

ShortThe type of attestationpersonal | professional | legal | official
Control1..1
BindingThe codes SHALL be taken from CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1

The way in which a person authenticated a composition.

Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Indicates the level of authority of the attestation.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Composition.attester.time
Definition

When the composition was attested by the party.

ShortWhen the report was attested by the partyWhen the composition was attested
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Composition.attester.party
Definition

Who attested the composition in the specified way.

ShortWho attested the reportWho attested the composition
Comments

For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson

Control0..1
TypeReference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Composition.event
Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

ShortThe laboratory service(s) being documentedThe clinical service(s) being documented
Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Composition.event.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
58. Composition.event.code
Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

ShortCode(s) that apply to the laboratory service(s) being documentedCode(s) that apply to the event being documented
Comments

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

Control0..*
BindingFor example codes, see v3 Code System ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode

This list of codes represents the main clinical acts being documented.

TypeCodeableConcept
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Composition.event.period
Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

ShortPeriod of time covered by the documentationThe period covered by the documentation
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
62. Composition.event.detail
Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

ShortThe laboratory service(s) being documentedThe event(s) being documented
Control0..*
TypeReference(Resource)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
64. Composition.section
Definition

The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format.


The root of the sections that make up the composition.

ShortComposition is broken into sections
Control10..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • exists @ $this.section
  • exists @ $this.entry
66. Composition.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
68. Composition.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Composition.section.code
Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortConcept - reference to a terminology or just textClassification of section (recommended)
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.


The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Composition.section:lab-no-subsections
Slice Namelab-no-subsections
Definition

Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed.


The root of the sections that make up the composition.

ShortVariant 1: EU Laboratory Report section with entries and no sub-sectionsComposition is broken into sections
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
74. Composition.section:lab-no-subsections.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
76. Composition.section:lab-no-subsections.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control0..1
BindingThe codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
78. Composition.section:lab-no-subsections.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation.
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
80. Composition.section:lab-no-subsections.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Observation Results: laboratory, Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
82. Composition.section:lab-no-subsections.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Composition.section:lab-subsections
Slice Namelab-subsections
Definition

Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry.


The root of the sections that make up the composition.

ShortVariant 2: EU Laboratory Report section with one to many subsections Laboratory Report ItemComposition is broken into sections
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
86. Composition.section:lab-subsections.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
88. Composition.section:lab-subsections.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control0..1
BindingThe codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
90. Composition.section:lab-subsections.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..01
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
92. Composition.section:lab-subsections.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..0*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
94. Composition.section:lab-subsections.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control10..*
This element is affected by the following invariants: cmp-1
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Composition.section:lab-subsections.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
98. Composition.section:lab-subsections.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control10..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Composition.section:lab-subsections.section.code
Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.


A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortConcept - reference to a terminology or just textClassification of section (recommended)
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.


The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control10..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from For example codes, see Laboratory Study Typeshttp://hl7.org/fhir/ValueSet/doc-section-codes
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
102. Composition.section:lab-subsections.section.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation.
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
104. Composition.section:lab-subsections.section.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control10..*
This element is affected by the following invariants: cmp-2
TypeReference(Observation Results: laboratory, Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
106. Composition.section:lab-subsections.section.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
108. Composition.section:annotations
Slice Nameannotations
Definition

Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc.

Examples: Suggestion: This result should be evaluated in relation to the patient's medical history and clinical condition. Technical note: A list of accredited examination(s) is available at www.laboratory.com.


The root of the sections that make up the composition.

ShortAnnotation commentComposition is broken into sections
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
cmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
110. Composition.section:annotations.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.


Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
112. Composition.section:annotations.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code.

Control0..1
BindingFor example codes, see DocumentSectionCodeshttp://hl7.org/fhir/ValueSet/doc-section-codes

Classification of a section of a composition/document.

TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;48767-8&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. Composition.section:annotations.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control10..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. Composition.section:annotations.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..0*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Composition.section:annotations.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

Guidance on how to interpret the contents of this table can be found here

0. Composition
Definition

Laboratory Report composition.

ShortLaboratory Report composition
Comments

While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.

Control0..*
Is Modifierfalse
Summaryfalse
Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
dom-6: A resource should have narrative for robust management (text.`div`.exists())
2. Composition.id
Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

ShortLogical id of this artifact
Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Control0..1
Typeid
Is Modifierfalse
Summarytrue
4. Composition.meta
Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

ShortMetadata about the resource
Control0..1
TypeMeta
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
6. Composition.implicitRules
Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

ShortA set of rules under which this content was created
Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Control0..1
Typeuri
Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
8. Composition.language
Definition

The base language in which the resource is written.

ShortLanguage of the resource content
Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Control0..1
BindingThe codes SHOULD be taken from CommonLanguages: A human language.
Additional BindingsPurpose
AllLanguagesMax Binding
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
10. Composition.text
Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

ShortNarrative text
Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Control0..1
TypeNarrative
Is Modifierfalse
Summaryfalse
Alternate Namesnarrative, html, xhtml, display
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
12. Composition.contained
Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

ShortContained, inline Resources
Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Control0..*
TypeResource
Is Modifierfalse
Summaryfalse
Alternate Namesinline resources, anonymous resources, contained resources
14. Composition.extension
Definition

An Extension

ShortExtension
Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Composition.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
16. Composition.extension:versionNumber
Slice NameversionNumber
Definition

Version specific identifier for the composition, assigned when each version is created/updated.

ShortVersion-specific identifier for composition
Comments

While each resource, including the composition itself, has its own version identifier, this is a formal identifier for the logical version of the composition as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

Control0..*
This element is affected by the following invariants: ele-1
TypeExtension(versionNumber) (Extension Type: string)
Is Modifierfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
18. Composition.extension:basedOn-order-or-requisition
Slice NamebasedOn-order-or-requisition
Definition

This extension provides a link to the order [(Reference(ServiceRequest)] or requisition [ServiceRequest.requisition (i.e., 'Request.groupIdentifier')] that this report document is based on and fulfills.

ShortDocument Based On Order
Control0..*
TypeExtension(Document Based On Order) (Extension Type: Choice of: Identifier, Reference(ServiceRequest))
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
20. Composition.extension:basedOn-order-or-requisition.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
22. Composition.extension:basedOn-order-or-requisition.extension
Definition

An Extension

ShortExtension
Control0..0
TypeExtension
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
SlicingThis element introduces a set of slices on Composition.extension.extension. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • value @ url
24. Composition.extension:basedOn-order-or-requisition.url
Definition

Source of the definition for the extension code - a logical name or a URL.

Shortidentifies the meaning of the extension
Comments

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

Control1..1
Typeuri
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
Fixed Valuehttp://hl7.eu/fhir/StructureDefinition/composition-basedOn-order-or-requisition
26. Composition.extension:basedOn-order-or-requisition.value[x]
Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

ShortValue of extension
Control0..1
TypeReference(ServiceRequest)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.extension.value[x]. The slices are unordered and Closed, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • type @ $this
28. Composition.extension:basedOn-order-or-requisition.value[x]:valueReference
Slice NamevalueReference
Definition

Value of extension - must be one of a constrained set of the data types (see Extensibility for a list).

ShortValue of extension
Control0..1
TypeReference(ServiceRequest: Laboratory Order)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
30. Composition.extension:information-recipient
Slice Nameinformation-recipient
Definition

This extension applies to the Composition resource and is used to represent an intended recipient of the composition.

ShortInformation recipient
Control0..*
TypeExtension(Information recipient) (Extension Type: Reference(Practitioner, Device, Patient, RelatedPerson, PractitionerRole, Organization))
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
32. Composition.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Summaryfalse
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
34. Composition.identifier
Definition

Identifiers assigned to this Laboratory Report by the performer or other systems. It shall be common to several report versions

ShortReport identifier
Comments

Composition.identifier SHALL be equal to one of the DiagnosticReport.identifier, if at least one exists

NoteThis is a business identifier, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
36. Composition.status
Definition

The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document.

ShortStatus of the Report
Comments

DiagnosticReport.status and Composition.status shall be aligned, based on the http://hl7.eu/fhir/laboratory/ConceptMap/ConceptMap-eu-diagRptStatus2CompStatus mapping

Control1..1
BindingThe codes SHALL be taken from CompositionStatus: The workflow/clinical status of the composition.
Typecode
Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

Need to be able to mark interim, amended, or withdrawn compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
38. Composition.type
Definition

Specifies that it refers to a Laboratory Report

ShortType of (Laboratory) Report
Comments

At least one DiagnosticReport.code.coding and Composition.type.coding SHALL be equal

Control1..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from Laboratory Report Types
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Key metadata element describing the composition, used in searching/filtering.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
40. Composition.category
Definition

A code that classifies this laboratory report.

ShortReport Category
Comments

DiagnosticReport.category and Composition.category shall be aligned

Control0..*
BindingFor example codes, see DocumentClassValueSet: High-level kind of a clinical document at a macro level.
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.category. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • pattern @ $this
42. Composition.category:studyType
Slice NamestudyType
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortCategorization of Composition
Comments

This is a metadata field from XDS/MHD.

Control0..*
BindingThe codes SHALL be taken from Laboratory Study Types
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
44. Composition.category:specialty
Slice Namespecialty
Definition

A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type.

ShortCategorization of Composition
Comments

This is a metadata field from XDS/MHD.

Control0..*
BindingThe codes SHALL be taken from Laboratory Specialty
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Requirements

Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
46. Composition.subject
Definition

Who or what this report is about. The report can be about a human patient, a living subject, a device (e.g. a machine), a location or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).

ShortWho and/or what this report is about
Comments

DiagnosticReport and Composition SHALL have the same subject

Control1..1
TypeReference(Patient: Person, Patient: Animal, Group, Location, Device)
Is Modifierfalse
Summarytrue
Requirements

Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
48. Composition.encounter
Definition

The healthcare event (e.g. a patient and healthcare provider interaction) which this DiagnosticReport is about.

ShortThe healthcare event which this Laboratory Report is about (when test ordered).
Comments

This will typically be the encounter the event occurred within, but some events may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission laboratory tests).

Control0..1
TypeReference(Encounter)
Is Modifierfalse
Summarytrue
Requirements

Provides context for the composition and supports searching.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
50. Composition.date
Definition

The composition editing time, when the composition was last logically changed by the author.

ShortComposition editing time
Comments

The Last Modified Date on the composition may be after the date of the document was attested without being changed.

Control1..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Requirements

dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
52. Composition.author
Definition

Identifies who is responsible for the information in the Laboratory Report, not necessarily who typed it in.

ShortWho and/or what authored the Laboratory Report
Comments

If a DiagnosticReport.resultsInterpreter exists this is expected to be a Composition.author; otherwise a DiagnosticReport.performer should be an author.

Control1..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summarytrue
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
54. Composition.title
Definition

Official human-readable label for the composition.

ShortLaboratory Report
Comments

For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
56. Composition.confidentiality
Definition

The code specifying the level of confidentiality of the Composition.

ShortAs defined by affinity domain
Comments

The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not.

Control0..1
BindingThe codes SHALL be taken from v3.ConfidentialityClassification (2014-03-26): Codes specifying the level of confidentiality of the composition.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
58. Composition.attester
Definition

A participant who has attested to the accuracy of the composition/document.

ShortAttests the report accuracy
Comments

Only list each attester once.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Requirements

Identifies responsibility for the accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
60. Composition.attester.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
62. Composition.attester.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
64. Composition.attester.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
66. Composition.attester.mode
Definition

The type of attestation the authenticator offers.

ShortThe type of attestation
Control1..1
BindingThe codes SHALL be taken from CompositionAttestationMode: The way in which a person authenticated a composition.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Indicates the level of authority of the attestation.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
68. Composition.attester.time
Definition

When the composition was attested by the party.

ShortWhen the report was attested by the party
Control0..1
TypedateTime
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
70. Composition.attester.party
Definition

Who attested the composition in the specified way.

ShortWho attested the report
Comments

For a Laboratory Report it is usually non expected that the attester would be a Patient or a RealtedPerson

Control0..1
TypeReference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who has taken on the responsibility for accuracy of the composition content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
72. Composition.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information.

ShortOrganization which maintains the composition
Comments

This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.

Control0..1
TypeReference(Organization)
Is Modifierfalse
Summarytrue
Requirements

Identifies where to go to find the current version, where to report issues, etc.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
74. Composition.relatesTo
Definition

Relationships that this composition has with other compositions or documents that already exist.

ShortRelationships to other compositions/documents
Comments

A document is a version specific composition.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
76. Composition.relatesTo.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
78. Composition.relatesTo.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
80. Composition.relatesTo.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
82. Composition.relatesTo.code
Definition

The type of relationship that this composition has with anther composition or document.

Shortreplaces | transforms | signs | appends
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Control1..1
BindingThe codes SHALL be taken from DocumentRelationshipType: The type of relationship between documents.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
84. Composition.relatesTo.target[x]
Definition

The target composition/document of this relationship.

ShortTarget of the relationship
Control1..1
TypeChoice of: Identifier, Reference(Composition)
[x] NoteSee Choice of Data Types for further information about how to use [x]
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
86. Composition.event
Definition

The clinical service, such as a colonoscopy or an appendectomy, being documented.

ShortThe laboratory service(s) being documented
Comments

The event needs to be consistent with the type element, though can provide further information if desired.

Control0..*
TypeBackboneElement
Is Modifierfalse
Summarytrue
Requirements

Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
88. Composition.event.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
90. Composition.event.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
92. Composition.event.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
94. Composition.event.code
Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

ShortCode(s) that apply to the laboratory service(s) being documented
Comments

An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries.

Control0..*
BindingFor example codes, see v3 Code System ActCode: This list of codes represents the main clinical acts being documented.
TypeCodeableConcept
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
96. Composition.event.period
Definition

The period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time.

ShortPeriod of time covered by the documentation
Control0..1
TypePeriod
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
98. Composition.event.detail
Definition

The description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy.

ShortThe laboratory service(s) being documented
Control0..*
TypeReference(Resource)
Is Modifierfalse
Summarytrue
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
100. Composition.section
Definition

The "body" of the report is organized as a tree of up to two levels of sections: top level sections represent laboratory specialties. A top level section SHALL contain either one text block carrying all the text results produced for this specialty along with Laboratory Data Entries or a set of Laboratory Report Item Sections. In the first case the specialty section happens to also be a leaf section. In the latter case, each (second level) leaf section contained in the (top level) specialty section represents a Report Item: i.e., a battery, a specimen study (especially in microbiology), or an individual test. In addition, any leaf section SHALL contain a Laboratory Data Entries containing the observations of that section in a machine-readable format.

ShortComposition is broken into sections
Control1..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
SlicingThis element introduces a set of slices on Composition.section. The slices are unordered and Open, and can be differentiated using the following discriminators: , and can be differentiated using the following discriminators:
  • exists @ $this.section
  • exists @ $this.entry
102. Composition.section.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
104. Composition.section.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
106. Composition.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
108. Composition.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
110. Composition.section.code
Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

ShortConcept - reference to a terminology or just text
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control1..1
This element is affected by the following invariants: ele-1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
112. Composition.section.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
114. Composition.section.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
116. Composition.section.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
118. Composition.section.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
120. Composition.section.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
122. Composition.section.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..*
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
124. Composition.section.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
126. Composition.section.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..*
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
128. Composition.section:lab-no-subsections
Slice Namelab-no-subsections
Definition

Variant 1: With this option, all laboratory report data entries are provided in the top level sections and no sub-sections are allowed.

ShortVariant 1: EU Laboratory Report section with entries and no sub-sections
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
130. Composition.section:lab-no-subsections.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
132. Composition.section:lab-no-subsections.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
134. Composition.section:lab-no-subsections.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
136. Composition.section:lab-no-subsections.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
138. Composition.section:lab-no-subsections.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control0..1
BindingThe codes SHOULD be taken from Laboratory Study Types
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
140. Composition.section:lab-no-subsections.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
142. Composition.section:lab-no-subsections.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
144. Composition.section:lab-no-subsections.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation.
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
146. Composition.section:lab-no-subsections.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
148. Composition.section:lab-no-subsections.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
150. Composition.section:lab-no-subsections.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Observation Results: laboratory)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
152. Composition.section:lab-no-subsections.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
154. Composition.section:lab-no-subsections.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
156. Composition.section:lab-subsections
Slice Namelab-subsections
Definition

Variant 2: With this option, this top level section doesn't include NEITHER a top level text NOR entry elements. Each Report Item is contained in a corresponding sub-sections which contains the Lab Report Data Entry.

ShortVariant 2: EU Laboratory Report section with one to many subsections Laboratory Report Item
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
158. Composition.section:lab-subsections.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
160. Composition.section:lab-subsections.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
162. Composition.section:lab-subsections.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
164. Composition.section:lab-subsections.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
166. Composition.section:lab-subsections.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control0..1
BindingThe codes SHOULD be taken from Laboratory Study Types
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
168. Composition.section:lab-subsections.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
170. Composition.section:lab-subsections.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
172. Composition.section:lab-subsections.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..0
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
174. Composition.section:lab-subsections.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
176. Composition.section:lab-subsections.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
178. Composition.section:lab-subsections.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..0
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
180. Composition.section:lab-subsections.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
182. Composition.section:lab-subsections.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control1..*
This element is affected by the following invariants: cmp-1
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
184. Composition.section:lab-subsections.section.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
186. Composition.section:lab-subsections.section.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
188. Composition.section:lab-subsections.section.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
190. Composition.section:lab-subsections.section.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control1..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
192. Composition.section:lab-subsections.section.code
Definition

A concept that may be defined by a formal reference to a terminology or ontology or may be provided by text.

ShortConcept - reference to a terminology or just text
Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Control1..1
This element is affected by the following invariants: ele-1
BindingThe codes SHOULD be taken from Laboratory Study Types
TypeCodeableConcept(Codeable Concept (IPS))
Is Modifierfalse
Requirements

Provides computable standardized labels to topics within the document.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
194. Composition.section:lab-subsections.section.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
196. Composition.section:lab-subsections.section.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
198. Composition.section:lab-subsections.section.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation.
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control0..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
200. Composition.section:lab-subsections.section.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
202. Composition.section:lab-subsections.section.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
204. Composition.section:lab-subsections.section.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control1..*
This element is affected by the following invariants: cmp-2
TypeReference(Observation Results: laboratory)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
206. Composition.section:lab-subsections.section.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
208. Composition.section:lab-subsections.section.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
210. Composition.section:annotations
Slice Nameannotations
Definition

Narrative expression of comments accompanying the report, such as suggestions for evaluation, technical notes from the laboratory, etc.

ShortAnnotation comment
Control0..*
TypeBackboneElement
Is Modifierfalse
Summaryfalse
Invariantscmp-1: A section must contain at least one of text, entries, or sub-sections (text.exists() or entry.exists() or section.exists())
cmp-2: A section can only have an emptyReason if it is empty (emptyReason.empty() or entry.empty())
ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
212. Composition.section:annotations.id
Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

ShortUnique id for inter-element referencing
Control0..1
Typestring
Is Modifierfalse
XML FormatIn the XML format, this property is represented as an attribute.
Summaryfalse
214. Composition.section:annotations.extension
Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

ShortAdditional content defined by implementations
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifierfalse
Summaryfalse
Alternate Namesextensions, user content
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
216. Composition.section:annotations.modifierExtension
Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

ShortExtensions that cannot be ignored even if unrecognized
Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Control0..*
TypeExtension
Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Summarytrue
Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Alternate Namesextensions, user content, modifiers
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
218. Composition.section:annotations.title
Definition

The label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents.

ShortLabel for section (e.g. for ToC)
Comments

The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.

Control0..1
Typestring
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized.

Alternate Namesheader, label, caption
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
220. Composition.section:annotations.code
Definition

A code identifying the kind of content contained within the section. This must be consistent with the section title.

ShortClassification of section (recommended)
Comments

The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document.

Control0..1
BindingFor example codes, see DocumentSectionCodes: Classification of a section of a composition/document.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Provides computable standardized labels to topics within the document.

Pattern Value&lt;valueCodeableConcept&nbsp;xmlns=&quot;http://hl7.org/fhir&quot;&gt;<br/>&nbsp;&nbsp;&lt;coding&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;system&nbsp;value=&quot;http://loinc.org&quot;/&gt;<br/>&nbsp;&nbsp;&nbsp;&nbsp;&lt;code&nbsp;value=&quot;48767-8&quot;/&gt;<br/>&nbsp;&nbsp;&lt;/coding&gt;<br/>&lt;/valueCodeableConcept&gt;<br/>
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
222. Composition.section:annotations.author
Definition

Identifies who is responsible for the information in this section, not necessarily who typed it in.

ShortWho and/or what authored the section
Control0..*
TypeReference(Practitioner, PractitionerRole, Device, Patient, RelatedPerson, Organization)
Is Modifierfalse
Summaryfalse
Requirements

Identifies who is responsible for the content.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
224. Composition.section:annotations.focus
Definition

The actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources).

ShortWho/what the section is about, when it is not about the subject of composition
Comments

Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.

Control0..1
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
226. Composition.section:annotations.text
Definition

A human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative.

ShortText summary of the section, for human interpretation
Comments

Document profiles may define what content should be represented in the narrative to ensure clinical safety.

Control1..1
This element is affected by the following invariants: cmp-1
TypeNarrative
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
228. Composition.section:annotations.mode
Definition

How the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted.

Shortworking | snapshot | changes
Comments

This element is labeled as a modifier because a change list must not be misunderstood as a complete list.

Control0..1
BindingThe codes SHALL be taken from ListMode: The processing mode that applies to this section.
Typecode
Is Modifierfalse
Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
Summaryfalse
Requirements

Sections are used in various ways, and it must be known in what way it is safe to use the entries in them.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
230. Composition.section:annotations.orderedBy
Definition

Specifies the order applied to the items in the section entries.

ShortOrder of section entries
Comments

Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order.

Control0..1
BindingThe codes SHOULD be taken from ListOrderCodes: What order applies to the items in the entry.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
232. Composition.section:annotations.entry
Definition

A reference to the actual resource from which the narrative in the section is derived.

ShortA reference to data that supports this section
Comments

If there are no entries in the list, an emptyReason SHOULD be provided.

Control0..0
This element is affected by the following invariants: cmp-2
TypeReference(Resource)
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
234. Composition.section:annotations.emptyReason
Definition

If the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason.

ShortWhy the section is empty
Comments

The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases.

Control0..1
This element is affected by the following invariants: cmp-2
BindingThe codes SHOULD be taken from ListEmptyReasons: If a section is empty, why it is empty.
TypeCodeableConcept
Is Modifierfalse
Summaryfalse
Requirements

Allows capturing things like "none exist" or "not asked" which can be important for most lists.

Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
236. Composition.section:annotations.section
Definition

A nested sub-section within this section.

ShortNested Section
Comments

Nested sections are primarily used to help human readers navigate to particular portions of the document.

Control0..0
This element is affected by the following invariants: cmp-1
TypeSee ttp://hl7.org/fhir/StructureDefinition/Composition#Composition.section
Is Modifierfalse
Summaryfalse
Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))