Clinical Document

  • Version 3
  • Publié le
  • Mise à jour le

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.

Diagrammes connexes

Contraintes

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Stéréotypes

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Attributs

AttributTypeMultiplicitéNote sur l’attribut
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.

Relations

Classe d’origine Multiplicité d’origine Relation Classe de destination Multiplicité de destination
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..*

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Comment citer ce contenu:

Institut canadien d’information sur la santé. Clinical Document. Consulté le 02 novembre 2026.

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