Clinical Document
A coherent set of information that is a statement of health care information, including clinical observations and services. A document is a set of resources/clinical concepts with a fixed presentation that is authored and/or attested by humans, organizations and devices.
Appears in
Constraints
n/a
Stereotype(s)
n/a
Attributes
| Attribute | Type | Multiplicity | Attribute note |
|---|---|---|---|
| Clinical Document Identifier | Identifier | 0..* | A version-independent, clinical document identifier. |
| Clinical Document Category Code | Codeable Concept | 0..* | Uniquely specifies a categorization/kind of a clinical document (e.g., referral, note, consent).
Value Set: To be developed.
(LOINC Document Ontology - Document Kind) |
| Clinical Document Type Code | Codeable Concept | 1 | Uniquely specifies a particular kind of clinical document (e.g., history and physical, discharge summary, progress note). This usually equates to the purpose of creating the clinical document.
Value Set: To be developed. |
| Clinical Document Confidentiality Code | Codeable Concept | 0..1 | Uniquely specifies a security classification of a clinical document.
Value Set: To be developed. |
| Clinical Document Date Time | Date Time | 1 | The date and, if known, the time, as of which the clinical document is valid. |
| Clinical Document Status Code | Codeable Concept | 1 | Unique specifies a status of the content of the clinical document (e.g., partial, preliminary).
Value Set: https://hl7.org/fhir/R4/valueset-composition-status.html |
| Clinical Document Version | String | 0..1 | An explicitly assigned identifier of a variation of the content in the clinical document. |
| Clinical Document Title | String | 0..1 | A human-readable name of the clinical document. |
| Clinical Document Language Code | Codeable Concept | 0..1 | Unique specifies the human language of the clinical document content (e.g., English, French).
Value Set: To be developed. |
Relationships
| From class | From multiplicity | Relationship | To class | To multiplicity |
|---|---|---|---|---|
| Clinical Document | 0..* | supports | Patient Immunization | 0..* |
| Document Attester | 0..* | verifies | Clinical Document | 1..* |
| Clinical Document | 0..* | for | Health Care Service Party Role Location | 0..* |
| Clinical Document | 0..* | has (aggregation) | Attachment | 0..* |
| Clinical Document | 0..* | Clinical Document | 0..* | |
| Clinical Document | 0..* | supports | Service Request | 0..* |
| Clinical Document | 0..* | has context | Encounter | 0..1 |
| Clinical Document | 0..1 | has (aggregation) | Clinical Annotation | 0..* |
| Observation | 0..* | derived from | Clinical Document | 0..* |
| Clinical Document | 0..* | has (composition) | Clinical Document Section | 0..* |
| Document Reference | 0..* | applies to | Clinical Document | 0..* |
| Clinical Document | 0..* | supports | Medication Request | 0..* |
| Patient Consent | 0..* | scopes | Clinical Document | 0..* |
| Patient | 0..1 | subject of | Clinical Document | 0..* |
| Clinical Document | 0..* | covers | Health Event | 0..* |
| Clinical Document | 0..1 | has | Document Party Role | 1..* |
Contact us
If you have questions about this initiative, would like to be added to our stakeholder notification list or would like to participate in our consultations, please email us.
How to cite:
Canadian Institute for Health Information. Clinical Document. Accessed November 02, 2026.
