HL7® FHIR® Malaysia Core (MY Core) Implementation Guide
2.0.1 - ci-build
HL7® FHIR® Malaysia Core (MY Core) Implementation Guide
2.0.1 - ci-build
HL7® FHIR® Malaysia Core (MY Core) Implementation Guide - Local Development build (v2.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core | Version: 2.0.1 | |||
| Active as of 2024-03-13 | Computable Name: CompositionMyCore | |||
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.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   extension: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 |
| 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) |
| category:class |
Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example) |
 subject |
Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| 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) |
| custodian |
Σ | 1..1 | Reference(Organization) | Organization which maintains the composition |
| event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented |
| 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) |
 section |
C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2 |
 Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension: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 |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1From the FHIR Standard | |
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | |
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | |
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | |
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | |
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | |
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG |
| 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 Filter: |
|---|---|---|---|---|
| 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 | |
| extension: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 | |
| extension: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 | ||||
| Path | Conformance | ValueSet | URI |
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | |
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | |
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | |
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | |
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | |
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension: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 Constraints: cmp-1, cmp-2 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension: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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1From the FHIR Standard | ||||
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | ||||
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | ||||
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1From the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1From the FHIR Standard | ||||
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | ||||
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1From the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderFrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonFrom the FHIR Standard |
| 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:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| Composition |
0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension: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 |
| 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) |
| category:class |
Σ | 0..1 | CodeableConcept | Categorization of Composition Binding: ValueSetCompositionClass (MY Core) (example) |
| subject |
Σ | 1..1 | Reference(Patient) | Who and/or what the composition is about |
| 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) |
| custodian |
Σ | 1..1 | Reference(Organization) | Organization which maintains the composition |
| event |
Σ | 1..* | BackboneElement | The clinical service(s) being documented |
| 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) |
| section |
C | 1..* | BackboneElement | Composition is broken into sections Constraints: cmp-1, cmp-2 |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension: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 |
| code |
1..1 | CodeableConcept | Classification of section (recommended) Binding: ValueSetCompositionSection (MY Core) (example) | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1From the FHIR Standard | |
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | |
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | |
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | |
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | |
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | |
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | |
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG |
| 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 Filter: |
|---|---|---|---|---|
| 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 | |
| extension: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 | |
| extension: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 | ||||
| Path | Conformance | ValueSet | URI |
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | |
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | |
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | |
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | |
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | |
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension: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 Constraints: cmp-1, cmp-2 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension: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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| Composition.language | preferred | CommonLanguageshttp://hl7.org/fhir/ValueSet/languagesFrom the FHIR Standard
| ||||
| Composition.status | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1From the FHIR Standard | ||||
| Composition.type | extensible | ValueSetCompositionTypeMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-type-my-coreFrom this IG | ||||
| Composition.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesFrom the FHIR Standard | ||||
| Composition.category:category | example | ValueSetCompositionCategoryMyCore(a valid code from CodeSystemCompositionCategory (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-coreFrom this IG | ||||
| Composition.category:class | example | ValueSetCompositionClassMyCore(a valid code from CodeSystemCompositionClass (MYCore))http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-coreFrom this IG | ||||
| Composition.confidentiality | required | v3.ConfidentialityClassificationhttp://terminology.hl7.org/ValueSet/v3-ConfidentialityClassificationFrom the FHIR Standard | ||||
| Composition.attester.mode | required | CompositionAttestationModehttp://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1From the FHIR Standard | ||||
| Composition.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1From the FHIR Standard | ||||
| Composition.event.code | extensible | ValueSetCompositionEventMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-event-my-coreFrom this IG | ||||
| Composition.section.code | example | ValueSetCompositionSectionMyCorehttp://fhir.hie.moh.gov.my/ValueSet/composition-section-my-coreFrom this IG | ||||
| Composition.section.mode | required | ListModehttp://hl7.org/fhir/ValueSet/list-mode|4.0.1From the FHIR Standard | ||||
| Composition.section.orderedBy | preferred | ListOrderCodeshttp://hl7.org/fhir/ValueSet/list-orderFrom the FHIR Standard | ||||
| Composition.section.emptyReason | preferred | ListEmptyReasonshttp://hl7.org/fhir/ValueSet/list-empty-reasonFrom the FHIR Standard |
| 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:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
This structure defines these elements as mandatory data fields:
| Element | Description |
|---|---|
Composition.status
|
Status of the Composition in the workflow. |
Composition.type
|
Type of Composition, e.g. physician note, nurse note, discharge summary, maternal health record. |
Composition.category
|
General category of the Composition, e.g. note, sub-record, referral. |
Composition.subject
|
References the Patient who is the subject of the Composition. |
Composition.date
|
The date on which the Composition is written. |
Composition.author
|
References who is responsible for the content of the Composition, e.g. Practitioner, PractitionerRole, Organization. |
Composition.title
|
A human-readable title for the Composition, usually same as type of Composition. |
Composition.custodian
|
References the Organization responsible for maintenance and access to the Composition. |
Composition.event
|
The clinical service related to the Composition, e.g. pre-hajj exam, routine medical exam, medication counselling. |
Composition.section
|
The sections that make up the Composition e.g. problem list, care plan, addendum. |
This structure slices the following elements:
| Element | Discriminator Path (Type) | Value |
|---|---|---|
Composition.category
|
:category.coding.system(Value)
|
http://fhir.hie.moh.gov.my/CodeSystem/composition-category-my-core |
:class.coding.system(Value)
|
http://fhir.hie.moh.gov.my/CodeSystem/composition-class-my-core |
IG © 2022+ MHNexus Sdn Bhd. Package hl7.fhir.MyCore#2.0.1 based on FHIR 4.0.1. Generated 2025-08-27
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