Composition (MY Core)

This profile is derived from the base FHIR Composition resource. In the Malaysian context, this resource is also used to manage MedicationRequest lists, create sub-records for Maternal and Child Health, Hajj medical screening programs, and International Patient Summaries.

Metadata

These are the details for this resource:

Name	Description	Canonical_URL	Status	Version
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. A Composition defines the structure and narrative content necessary for a document.	http://fhir.hie.moh.gov.my/StructureDefinition/Composition-my-core	active	1.0.0

Resource content

These are the different views of this resource:

Mandatory Data Elements

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.

Slices

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

Extensions

These are the extensions within this resource:

Name	Path	URL
locationRecorded	Composition.extension:locationRecorded	http://fhir.hie.moh.gov.my/StructureDefinition/location-recorded-my-core
sectionDate	Composition.section.extension:sectionDate	http://fhir.hie.moh.gov.my/StructureDefinition/composition-section-date-my-core

Terminology Bindings

These are the terminology bindings within this resource:

Path	Conformance	ValueSet
Composition.language	preferred	http://hl7.org/fhir/ValueSet/languages
Composition.status	required	http://hl7.org/fhir/ValueSet/composition-status|4.0.1
Composition.type	extensible	http://fhir.hie.moh.gov.my/ValueSet/composition-type-my-core
Composition.category	example	http://hl7.org/fhir/ValueSet/document-classcodes
Composition.category:category	example	http://fhir.hie.moh.gov.my/ValueSet/composition-category-my-core
Composition.category:class	example	http://fhir.hie.moh.gov.my/ValueSet/composition-class-my-core
Composition.confidentiality	required	http://terminology.hl7.org/ValueSet/v3-ConfidentialityClassification
Composition.attester.mode	required	http://hl7.org/fhir/ValueSet/composition-attestation-mode|4.0.1
Composition.relatesTo.code	required	http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
Composition.event.code	extensible	http://fhir.hie.moh.gov.my/ValueSet/composition-event-my-core
Composition.section.code	example	http://fhir.hie.moh.gov.my/ValueSet/composition-section-my-core
Composition.section.mode	required	http://hl7.org/fhir/ValueSet/list-mode|4.0.1
Composition.section.orderedBy	preferred	http://hl7.org/fhir/ValueSet/list-order
Composition.section.emptyReason	preferred	http://hl7.org/fhir/ValueSet/list-empty-reason