A COMPOSITION represents the set of RECORD_COMPONENTs composed (authored) during one clinical encounter or documentation session, and committed within one EHR.

Attributes

Name	Data type	Occurs	Description	Value Constraints
name	SC	1..1	The name, expressed as a coded value or as plain text, specifies the clinical or administrative concept to which this EHR node corresponds, as labelled in the EHR system in which it was first committed.
archetype_id	ST	0..1	The unique identifier of the archetype node to which this RECORD_COMPONENT corresponds, either in the EHR Provider system or as a mapping produced when this EHR_EXTRACT was created. The syntax for populating this attribute value is defined in EN 13606-2:2008. Within the LRA the value assigned to this attribute SHALL have no effect on the interpretation of instances of this class and the attribute SHALL not be used as a predicate for semantic data retrieval.
meaning	CD.CV.SCT	1..1	The standardised clinical or administrative concept to which the name attribute has been mapped. In archetyped systems it will correspond to the archetype node name. In non-archetyped systems it might be a coded term from an appropriate terminology system. Within the LRA, this attribute is used by the COMPOSITION class to provide a coded representation of the type of composition, e.g. Progress note, Laboratory test result form, Radiology report, Referral letter, Clinic visit, Clinic letter, Discharge summary, etc.	code Semantic expression constraint
rc_id	II	1..1	The globally-unique identifier by which this node in the EHR hierarchy is referenced in the EHR system to which the data were first committed. This identifier shall be retained by the EHR Recipient and re-used whenever this RECORD_COMPONENT is subsequently included in another EHR_EXTRACT.
synthesised	BL	1..1	This attribute value shall be TRUE if this RECORD_COMPONENT has been created in order to comply with this standard , but this point in the EHR hierarchy has no corresponding node in the EHR from which it was extracted.	value Default value: false
policy_ids	II	0..*	This attribute identifies one or more access control policies that specifically pertain to this RECORD_COMPONENT and which need to be communicated to the EHR Recipient to govern future access to it. The identifiers may refer to policy information included in this EHR_EXTRACT as defined in EN 13606-4:2007, or to policies held in external policy servers to which the EHR Recipient has access.
sensitivity	INT.Pos	0..1	The sensitivity of this RECORD_COMPONENT, represented using the code set for this attribute defined in EN 13606-4:2007.
orig_parent_ref	II	0..1	The identity of the RECORD_COMPONENT that is the original parent (context) for this RECORD_COMPONENT, to be present if this information has been copied from another part of the EHR of this subject of care..
session_time	IVL_TS	1..1	The date and time or interval during which the clinical encounter or documentation session occurred.
territory	CD.CV	0..1	Code for the territory in which this COMPOSITION was created, identified by ISO 3166. This will indicate the country under whose laws this COMPOSITION was created.
contribution_id	II	0..1	This optional identifier may be used to logically group the set of COMPOSITIONs committed by one user at one point in time in the EHR of one subject of care, if an EHR system has permitted data to be committed simultaneously into multiple COMPOSITIONs.

Contained ENTRYs

Name	ENTRY Class	Occurs	Description
content	ClinicalNarrative	0..*
content	CareIssues	0..*
content	CommunityServiceActionPlan	0..*
content	AdmissionRelatedInformation	0..1
content	RisksGoalsAndExpectations	0..*
content	StoppedMedicationActivity	0..*
content	DischargeDetails	0..1
content	ProcedureActivity	0..*
content	Diagnosis	0..*
content	GPActionPlan	0..*
content	AllergiesOrAdverseReactionPropensity	0..*
content	ProvisionOfInformationAndAdvice	0..*
content	CurrentMedicationActivity	0..*
content	MedicationRecommendation	0..*
content	AllergiesOrAdverseReactionEvent	0..*
content	HospitalActionPlan	0..*

Participations

Committal Information

Name	Class	Occurs	Description
committal	CommitterAuditInfo	1..1	This class represents the committal and revision data about a RECORD_COMPONENT. Through the committal association from COMPOSITION this class represents the committal and revision data about this COMPOSITION in the EHR Provider system. Through the feeder_audit association from RECORD_COMPONENT this class represents the committal and revision data about this RECORD_COMPONENT in the original EHR system in which it was first committed.

Composer

Name	Class	Occurs	Description
composer	ComposerFunctionalChoice	1..1	Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in the COMPOSITION. The ROLE class shall participate as the composer or author of the discharge summary.

Attestation Information

Name	Class	Occurs	Description
attestations	AttestationInfo	1..1	This class documents the details of any attestations that pertain to the RECORD_COMPONENTS within a COMPOSITION.

Other Participations

Name	Class	Occurs	Description
other_participations	DistributionListFunctionalChoice	0..1	Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in this COMPOSITION. The ROLE class shall participate as the recipient of a copy of the discharge summary.
other_participations	RecordTargetParticipationChoice	1..1	Represents a choice of FUNCTIONAL_ROLE classes used to describe the participation of a ROLE class in this COMPOSITION. The ROLE class shall participate as the primary target of the discharge summary record.

Reference Model Type

COMPOSITION