HL7 FHIR Malaysia Core (MY Core) Implementation Guide - Local Development build (v1.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: Composition (MY Core)

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. In the Malaysian context, this resource is also used to create sub-records for Maternal and Child Health, the Hajj medical screening program, and an International Patient Summary.

Usage:

• Derived from this Resource Profile: Composition Health Screening (MY Core)
• Examples for this Resource Profile: Composition/example-composition-amend-hie-dc-comp-12346-140423, Composition/example-composition-delete-hie-dc-comp-12348-140423, Composition/example-composition-health-screening-nhsi, Composition/example-composition-hie-dc-comp-12345-140423... Show 3 more, Composition/example-composition-myhix-template, Composition/example-composition-myhix and Composition/example-composition

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible) ele-1: All FHIR elements must have a @value or children
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example) ele-1: All FHIR elements must have a @value or children
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children
date	Σ	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children
title	Σ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required) ele-1: All FHIR elements must have a @value or children
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children
event	Σ	1..*	BackboneElement	The clinical service(s) being documented ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible) ele-1: All FHIR elements must have a @value or children
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category		1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:category		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
category:class		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
subject		1..1	Reference(Patient)	Who and/or what the composition is about
confidentiality		0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian		1..1	Reference(Organization)	Organization which maintains the composition
event		1..*	BackboneElement	The clinical service(s) being documented
code		0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section		1..*	BackboneElement	Composition is broken into sections
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	1..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Composition

Summary

Mandatory: 6 elements(2 nested mandatory elements)
Fixed: 2 elements

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
• http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.category

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible) ele-1: All FHIR elements must have a @value or children
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example) ele-1: All FHIR elements must have a @value or children
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about ele-1: All FHIR elements must have a @value or children
date	Σ	1..1	dateTime	Composition editing time ele-1: All FHIR elements must have a @value or children
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition ele-1: All FHIR elements must have a @value or children
title	Σ	1..1	string	Human Readable name/title ele-1: All FHIR elements must have a @value or children
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required) ele-1: All FHIR elements must have a @value or children
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition ele-1: All FHIR elements must have a @value or children
event	Σ	1..*	BackboneElement	The clinical service(s) being documented ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible) ele-1: All FHIR elements must have a @value or children
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example) ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from Composition

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
type		1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category		1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system
category:category		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
category:class		0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
coding
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
subject		1..1	Reference(Patient)	Who and/or what the composition is about
confidentiality		0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
custodian		1..1	Reference(Organization)	Organization which maintains the composition
event		1..*	BackboneElement	The clinical service(s) being documented
code		0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
section		1..*	BackboneElement	Composition is broken into sections
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
locationRecorded		0..1	Reference(Location) {r}	An extension to define where the Composition was recorded (Location Resource) URL: http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!Σ	1..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	Σ	1..1	CodeableConcept	Kind of composition (LOINC if possible) Binding: ValueSetCompositionType (MY Core) (extensible)
Slices for category	Σ	1..*	CodeableConcept	Categorization of Composition Slice: Unordered, Open by value:coding.system Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:category	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionCategory (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category:class	Σ	0..1	CodeableConcept	Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	Identity of the terminology system Fixed Value: http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	1..1	Reference(Patient)	Who and/or what the composition is about
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	Σ	1..1	dateTime	Composition editing time
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the composition
title	Σ	1..1	string	Human Readable name/title
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: V3 Value SetConfidentialityClassification (required)
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	1..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	1..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: ValueSetCompositionEvent (MY Core) (extensible)
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
section	C	1..*	BackboneElement	Composition is broken into sections cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty
id		0..1	string	Unique id for inter-element referencing
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
sectionDate		0..1	dateTime	Extension to define the date this section was created on URL: http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title		0..1	string	Label for section (e.g. for ToC)
code		1..1	CodeableConcept	Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example)
author		0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Who and/or what authored the section
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	C	0..1	Narrative	Text summary of the section, for human interpretation
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	C	0..*	Reference(Resource)	A reference to data that supports this section
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	C	0..*	See section (Composition)	Nested Section
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
Composition.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
Composition.status	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
Composition.type	extensible	ValueSetCompositionTypeMyCore (a valid code from CodeSystemCompositionType (MY Core)) http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core from this IG
Composition.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
Composition.category:category	example	ValueSetCompositionCategoryMyCore (a valid code from CodeSystemCompositionCategory (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core from this IG
Composition.category:class	example	ValueSetCompositionClassMyCore (a valid code from CodeSystemCompositionClass (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core from this IG
Composition.confidentiality	required	v3.ConfidentialityClassification http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification from the FHIR Standard
Composition.attester.mode	required	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1 from the FHIR Standard
Composition.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
Composition.event.code	extensible	ValueSetCompositionEventMyCore (a valid code from CodeSystemCompositionEvent (MYCore)) http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core from this IG
Composition.section.code	example	ValueSetCompositionSectionMyCore http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core from this IG
Composition.section.mode	required	ListMode http://hl7.org/fhir/ValueSet/list-mode|4.0.1 from the FHIR Standard
Composition.section.orderedBy	preferred	ListOrderCodes http://hl7.org/fhir/ValueSet/list-order from the FHIR Standard
Composition.section.emptyReason	preferred	ListEmptyReasons http://hl7.org/fhir/ValueSet/list-empty-reason from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
cmp-1	error	Composition.section	A section must contain at least one of text, entries, or sub-sections : text.exists() or entry.exists() or section.exists()
cmp-2	error	Composition.section	A section can only have an emptyReason if it is empty : emptyReason.empty() or entry.empty()
dom-2	error	Composition	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Composition	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Composition	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Composition	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Composition	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Composition

Summary

Mandatory: 6 elements(2 nested mandatory elements)
Fixed: 2 elements

Extensions

This structure refers to these extensions:

• http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
• http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of Composition.category

Other representations of profile: CSV, Excel, Schematron

Notes: