The Clinical Document profile constrains Composition to specify a clinical document (matching CDA). The base Composition is a general resource for compositions or documents about any kind of subject that might be encountered in healthcare including such things as guidelines, medicines, etc. A clinical document is focused on documents related to the provision of care process, where the subject is a patient, a group of patients, or a closely related concept. A clinical document has additional requirements around confidentiality that do not apply in the same way to other kinds of documents.

Represents orders that are fulfilled by this document such as a radiologist’s report of an x-ray.

Describes an information source for any content within the clinical document.

Represents information about a patient’s consents.

Identifies supporting entities, including parents, relatives, caregivers, insurance policyholders, guarantors, and others related in some way to the patient. A supporting person or organization is an individual or an organization with a relationship to the patient. A supporting person who is playing multiple roles would be recorded in multiple participants (e.g., emergency contact and next-of-kin).

Represents clinicians who actually and principally carry out the clinical services being documented. In a transfer of care this represents the healthcare providers involved in the current or pertinent historical care of the patient. Preferably, the patients key healthcare care team members would be listed, particularly their primary physician and any active consulting physicians, therapists, and counselors.

Records the intended recipient of the information at the time the document was created.

Represents the person who transferred the content, written or dictated, into the clinical document. To clarify, an author provides the content, subject to their own interpretation; a dataEnterer adds an author’s information to the electronic system.