Class ClinicalDocument

"A CDA document is comprised of a header and a body. The header identifies and classifies the document; provides information on authentication, the encounter, the patient, and the provider; and sets the context for the document as a whole. The body contains the clinical report, and is conceptually divided up into nested sections, each containing a narrative block to be rendered along with structured entries and external references." - HL7 CDA, ClinicalDocument
"A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.)." - HL7 FHIR, Composition

Attributes
AdministrativeClosureAct administrativeClosure administrativeClosure

This document was closed by Administrative Action.

AmendmentAct amendment amendment

Records the amendment of a clinical document.

PractitionerParticipation attester attester

"A participant who has attested to the accuracy of the composition/document." HL7 FHIR, Composition.attester

Attribution authenticator authenticator

"Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it." - HL7 CDA, ClinicalDocument.authenticator

PractitionerParticipation author author

"Represents the humans and/or machines that authored the document." HL7 CDA, ClinicalDocument.author
"Identifies who is responsible for the information in the composition, not necessarily who typed it in." HL7 FHIR, Composition.author

«CS» Code category category

"A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type." HL7 FHIR, Composition.category

«CS» Code confidentiality confidentiality

"Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value" HL7 CDA, ClinicalDocument.ConfidentialityCode
"The code specifying the level of confidentiality of the Composition." HL7 FHIR, Composition.confidentiality

Organization custodian custodian

"Represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian." - HL7 CDA, ClinicalDocument.custodian
"Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information." HL7 FHIR, Composition.custodian

Attribution dataEnterer dataEnterer

"Represents the participant who has transformed a dictated note into text." - HL7 CDA, ClinicalDocument.dataEnterer

«TS» PointInTime date date

"Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA." HL7 CDA, ClinicalDocument.effectiveTime
"The composition editing time, when the composition was last logically changed by the author." HL7 FHIR, Composition.date

«EntryPoint» EncounterEvent encounter encounter

"This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note." HL7 CDA, ClinicalDocument.EncompassingEncounter
"Describes the clinical encounter or type of care this documentation is associated with." HL7 FHIR, Composition.encounter

EventSummary event event

"The clinical service, such as a colonoscopy or an appendectomy, being documented." - HL7 FHIR, Composition.event

«II» Id identifier identifier

"Represents the unique instance identifier of a clinical document." HL7 CDA, ClinicalDocument.id
"A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time." HL7 FHIR, Composition.identifier

Image image image

Pointer to an image that might be associated with the document.

Attribution informant informant

"An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma." - HL7 CDA, ClinicalDocument.informant

Attribution informationRecipient informationRecipient

"Represents a recipient who should receive a copy of the document." - HL7 CDA, ClinicalDocument.informationRecipient

«CS» Code kind kind

"The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength." HL7 CDA, ClinicalDocument.code
"Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition." HL7 FHIR, Composition.type
Note that LOINC document titles are widely used for this property, and is highly encouraged.

«CS» Code language language

"Specifies the human language of character data (whether they be in contents or attribute values). The values of the attribute are language identifiers as defined by the IETF RFC 3066. Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value." - HL7 CDA, ClinicalDocument.languageCode

Attribution legalAuthenticator legalAuthenticator

"Represents a participant who has legally authenticated the document." - HL7 CDA, ClinicalDocument.legalAuthenticator

Attribution performer performer

"A performer is an entity in the role of assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization" - HL7 CDA, ClinicalDocument.performer

Patient recordTarget recordTarget

"The recordTarget represents the medical record that this document belongs to. A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated." HL7 CDA, ClinicalDocument.recordTarget
"Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure)." HL7 FHIR, Composition.subject
Note that in FHIR, the subject can be entities other than a Patient. In the FHIM (and in CDA), the subject (aka record target) is limited to the Patient to whom the medical record belongs.

RelatedDocument relatedDocument relatedDocument

Pointer to other Clinical Documents to which this Clinical Document is somehow associated.
"Relationships that this composition has with other compositions or documents that already exist." - HL7 FHIR, Composition.relatesTo

Attribution responsibleParty responsibleParty

"A responsibleParty is a person or organization in the role of an assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization." - HL7 CDA, ClinicalDocument.responsibleParty

NullifyAct retraction retraction

Records the retraction, or "nullification" of a clinical document.

ClinicalDocumentSection section section

Pointer to a set of sections that make up the document.
"Document sections can nest, can override context propagated from the header..., and can contain narrative and CDA entries." HL7 CDA, ClinicalDocument Section
"The root of the sections that make up the composition." HL7 FHIR, Composition.section

«II» Id setId setId

"Represents an identifier that is common across all document revisions." - HL7 CDA, ClinicalDocument.setId

«CS» Code status status

"The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document." HL7 FHIR, Composition.status

String title title

"Represents the title of the document. It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a consultation or progress note). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used." HL7 CDA, ClinicalDocument.title
"Official human-readable label for the composition." HL7 FHIR, Composition.title

Integer version version

"An integer value used to version successive replacement documents" - HL7 CDA, ClinicalDocument.versionNumber
Note that in FHIR, the version number is handled by the meta tags, so it is not an explicit property.


Properties:

Alias
Classifier Behavior
Is Abstractfalse
Is Activefalse
Is Leaffalse
Keywords
NameClinicalDocument
Name Expression
NamespaceClinicalDocument
Owned Template Signature
OwnerClinicalDocument
Owning Template Parameter
PackageClinicalDocument
Qualified NameFHIM::ClinicalDocument::ClinicalDocument
Representation
Stereotype
Template Parameter
VisibilityPublic

Attribute Details

 administrativeClosure
Public AdministrativeClosureAct administrativeClosure

This document was closed by Administrative Action.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_administrativeClosure
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameadministrativeClosure
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::administrativeClosure
Stereotype
Template Parameter
TypeAdministrativeClosureAct
Upper1
Upper Value(1)
VisibilityPublic


 amendment
Public AmendmentAct amendment

Records the amendment of a clinical document.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_amendment
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameamendment
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::amendment
Stereotype
Template Parameter
TypeAmendmentAct
Upper1
Upper Value(1)
VisibilityPublic


 attester
Public PractitionerParticipation attester

"A participant who has attested to the accuracy of the composition/document." HL7 FHIR, Composition.attester

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
Nameattester
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::attester
Stereotype
Template Parameter
TypePractitionerParticipation
Upper*
Upper Value(*)
VisibilityPublic


 authenticator
Public Attribution authenticator

"Represents a participant who has attested to the accuracy of the document, but who does not have privileges to legally authenticate the document. An example would be a resident physician who sees a patient and dictates a note, then later signs it." - HL7 CDA, ClinicalDocument.authenticator

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameauthenticator
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::authenticator
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 author
Public PractitionerParticipation author

"Represents the humans and/or machines that authored the document." HL7 CDA, ClinicalDocument.author
"Identifies who is responsible for the information in the composition, not necessarily who typed it in." HL7 FHIR, Composition.author

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1..*
Nameauthor
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::author
Stereotype
Template Parameter
TypePractitionerParticipation
Upper*
Upper Value(*)
VisibilityPublic


 category
Public «CS» Code category

"A categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type." HL7 FHIR, Composition.category

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
Namecategory
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::category
Stereotype
Template Parameter
Type«CS» Code
Upper*
Upper Value(*)
VisibilityPublic


 confidentiality
Public «CS» Code confidentiality

"Confidentiality is a required contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value" HL7 CDA, ClinicalDocument.ConfidentialityCode
"The code specifying the level of confidentiality of the Composition." HL7 FHIR, Composition.confidentiality

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameconfidentiality
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::confidentiality
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 custodian
Public Organization custodian

"Represents the organization that is in charge of maintaining the document. The custodian is the steward that is entrusted with the care of the document. Every CDA document has exactly one custodian." - HL7 CDA, ClinicalDocument.custodian
"Identifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information." HL7 FHIR, Composition.custodian

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Namecustodian
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::custodian
Stereotype
Template Parameter
TypeOrganization
Upper1
Upper Value(1)
VisibilityPublic


 dataEnterer
Public Attribution dataEnterer

"Represents the participant who has transformed a dictated note into text." - HL7 CDA, ClinicalDocument.dataEnterer

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedataEnterer
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::dataEnterer
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 date
Public «TS» PointInTime date

"Signifies the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created. The time when the transform occurred is not currently represented in CDA." HL7 CDA, ClinicalDocument.effectiveTime
"The composition editing time, when the composition was last logically changed by the author." HL7 FHIR, Composition.date

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namedate
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::date
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 encounter
Public «EntryPoint» EncounterEvent encounter

"This optional class represents the setting of the clinical encounter during which the documented act(s) or ServiceEvent occurred. Documents are not necessarily generated during an encounter, such as when a clinician, in response to an abnormal lab result, attempts to contact the patient but can't, and writes a Progress Note." HL7 CDA, ClinicalDocument.EncompassingEncounter
"Describes the clinical encounter or type of care this documentation is associated with." HL7 FHIR, Composition.encounter

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_encounter
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameencounter
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::encounter
Stereotype
Template Parameter
Type«EntryPoint» EncounterEvent
Upper1
Upper Value(1)
VisibilityPublic


 event
Public EventSummary event

"The clinical service, such as a colonoscopy or an appendectomy, being documented." - HL7 FHIR, Composition.event

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_event
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
Nameevent
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::event
Stereotype
Template Parameter
TypeEventSummary
Upper*
Upper Value(*)
VisibilityPublic


 identifier
Public «II» Id identifier

"Represents the unique instance identifier of a clinical document." HL7 CDA, ClinicalDocument.id
"A version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time." HL7 FHIR, Composition.identifier

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameidentifier
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::identifier
Stereotype
Template Parameter
Type«II» Id
Upper1
Upper Value(1)
VisibilityPublic


 image
Public Image image

Pointer to an image that might be associated with the document.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_image
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameimage
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::image
Stereotype
Template Parameter
TypeImage
Upper1
Upper Value(1)
VisibilityPublic


 informant
Public Attribution informant

"An informant (or source of information) is a person that provides relevant information, such as the parent of a comatose patient who describes the patient's behavior prior to the onset of coma." - HL7 CDA, ClinicalDocument.informant

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameinformant
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::informant
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 informationRecipient
Public Attribution informationRecipient

"Represents a recipient who should receive a copy of the document." - HL7 CDA, ClinicalDocument.informationRecipient

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameinformationRecipient
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::informationRecipient
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 kind
Public «CS» Code kind

"The code specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note). The value set is drawn from LOINC, and has a CWE coding strength." HL7 CDA, ClinicalDocument.code
"Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition." HL7 FHIR, Composition.type
Note that LOINC document titles are widely used for this property, and is highly encouraged.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namekind
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::kind
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 language
Public «CS» Code language

"Specifies the human language of character data (whether they be in contents or attribute values). The values of the attribute are language identifiers as defined by the IETF RFC 3066. Language is a contextual component of CDA, where the value expressed in the header holds true for the entire document, unless overridden by a nested value." - HL7 CDA, ClinicalDocument.languageCode

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Namelanguage
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::language
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 legalAuthenticator
Public Attribution legalAuthenticator

"Represents a participant who has legally authenticated the document." - HL7 CDA, ClinicalDocument.legalAuthenticator

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamelegalAuthenticator
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::legalAuthenticator
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 performer
Public Attribution performer

"A performer is an entity in the role of assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization" - HL7 CDA, ClinicalDocument.performer

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameperformer
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::performer
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 recordTarget
Public Patient recordTarget

"The recordTarget represents the medical record that this document belongs to. A clinical document typically has exactly one recordTarget participant. In the uncommon case where a clinical document (such as a group encounter note) is placed into more than one patient chart, more than one recordTarget participants can be stated." HL7 CDA, ClinicalDocument.recordTarget
"Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure)." HL7 FHIR, Composition.subject
Note that in FHIR, the subject can be entities other than a Patient. In the FHIM (and in CDA), the subject (aka record target) is limited to the Patient to whom the medical record belongs.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_recordTarget
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamerecordTarget
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::recordTarget
Stereotype
Template Parameter
TypePatient
Upper1
Upper Value(1)
VisibilityPublic


 relatedDocument
Public RelatedDocument relatedDocument

Pointer to other Clinical Documents to which this Clinical Document is somehow associated.
"Relationships that this composition has with other compositions or documents that already exist." - HL7 FHIR, Composition.relatesTo

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_relatedDocument
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity*
NamerelatedDocument
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::relatedDocument
Stereotype
Template Parameter
TypeRelatedDocument
Upper*
Upper Value(*)
VisibilityPublic


 responsibleParty
Public Attribution responsibleParty

"A responsibleParty is a person or organization in the role of an assigned entity (AssignedEntity class). An assigned entity is a person assigned to the role by the scoping organization." - HL7 CDA, ClinicalDocument.responsibleParty

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameresponsibleParty
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::responsibleParty
Stereotype
Template Parameter
TypeAttribution
Upper1
Upper Value(1)
VisibilityPublic


 retraction
Public NullifyAct retraction

Records the retraction, or "nullification" of a clinical document.

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_retraction
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameretraction
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::retraction
Stereotype
Template Parameter
TypeNullifyAct
Upper1
Upper Value(1)
VisibilityPublic


 section
Public ClinicalDocumentSection section

Pointer to a set of sections that make up the document.
"Document sections can nest, can override context propagated from the header..., and can contain narrative and CDA entries." HL7 CDA, ClinicalDocument Section
"The root of the sections that make up the composition." HL7 FHIR, Composition.section

Constraints:
Properties:

AggregationNone
Alias
AssociationclinicalDocument_section
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquefalse
Keywords
Lower0
Lower Value(0)
Multiplicity*
Namesection
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::section
Stereotype
Template Parameter
TypeClinicalDocumentSection
Upper*
Upper Value(*)
VisibilityPublic


 setId
Public «II» Id setId

"Represents an identifier that is common across all document revisions." - HL7 CDA, ClinicalDocument.setId

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamesetId
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::setId
Stereotype
Template Parameter
Type«II» Id
Upper1
Upper Value(1)
VisibilityPublic


 status
Public «CS» Code status

"The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document." HL7 FHIR, Composition.status

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namestatus
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::status
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 title
Public String title

"Represents the title of the document. It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of ClinicalDocument.code (e.g. a consultation or progress note). Where these display names are rendered to the clinician, or where the document has a unique title, the ClinicalDocument.title component should be used." HL7 CDA, ClinicalDocument.title
"Official human-readable label for the composition." HL7 FHIR, Composition.title

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Nametitle
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::title
Stereotype
Template Parameter
TypeString
Upper1
Upper Value(1)
VisibilityPublic


 version
Public Integer version

"An integer value used to version successive replacement documents" - HL7 CDA, ClinicalDocument.versionNumber
Note that in FHIR, the version number is handled by the meta tags, so it is not an explicit property.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassClinicalDocument
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Nameversion
Name Expression
NamespaceClinicalDocument
Opposite
OwnerClinicalDocument
Owning Association
Owning Template Parameter
Qualified NameFHIM::ClinicalDocument::ClinicalDocument::version
Stereotype
Template Parameter
TypeInteger
Upper1
Upper Value(1)
VisibilityPublic