administrativeClosure amendment attester"A participant who has attested to the accuracy of the composition/document." HL7 FHIR, Composition.attester
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
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
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
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
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
dataEnterer"Represents the participant who has transformed a dictated note into text." - HL7 CDA, ClinicalDocument.dataEnterer
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
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
event"The clinical service, such as a colonoscopy or an appendectomy, being documented." - HL7 FHIR, Composition.event
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
imagePointer to an image that might be associated with the document.
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
informationRecipient"Represents a recipient who should receive a copy of the document." - HL7 CDA, ClinicalDocument.informationRecipient
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.typeNote that LOINC document titles are widely used for this property, and is highly encouraged.
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
legalAuthenticator"Represents a participant who has legally authenticated the document." - HL7 CDA, ClinicalDocument.legalAuthenticator
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
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.subjectNote 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.
relatedDocumentPointer 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
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
retractionRecords the retraction, or "nullification" of a clinical document.
sectionPointer 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
setId"Represents an identifier that is common across all document revisions." - HL7 CDA, ClinicalDocument.setId
status"The workflow/clinical status of this composition. The status is a marker for the clinical standing of the document." HL7 FHIR, Composition.status
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
version"An integer value used to version successive replacement documents" - HL7 CDA, ClinicalDocument.versionNumberNote that in FHIR, the version number is handled by the meta tags, so it is not an explicit property.