Composition

Namespace: OpenEHR.RM.Composition, OpenEHR.RM.Composition.Content.Entry

A Composition is the top-level clinical document in openEHR — the unit of clinical meaning that a clinician creates, signs, and submits.

Composition

var composition = new Composition
{
    Name            = new DvText("Vital Signs"),
    ArchetypeNodeId = "openEHR-EHR-COMPOSITION.encounter.v1",
    ArchetypeDetails = new Archetyped
    {
        ArchetypeId = new ArchetypeId("openEHR-EHR-COMPOSITION.encounter.v1"),
        RmVersion   = "1.1.0"
    },
    Language  = new CodePhrase(new TerminologyId("ISO_639-1"), "en"),
    Territory = new CodePhrase(new TerminologyId("ISO_3166-1"), "GB"),
    Category  = new DvCodedText
    {
        Value        = "event",
        DefiningCode = new CodePhrase(new TerminologyId("openehr"), "433")
    },
    Composer = new PartyIdentified { Name = "Dr Alice Smith" },
    Context  = new EventContext
    {
        StartTime = new DvDateTime(DateTimeOffset.UtcNow.ToString("o")),
        Setting   = new DvCodedText { Value = "primary medical care", DefiningCode = … }
    },
    Content = new List<ContentItem> { myObservation }
};

Key mandatory properties:

Property	Description
Language	ISO 639-1 language code for the composition content
Territory	ISO 3166-1 country where the composition was created
Category	"event" (point-in-time) or "persistent" (ongoing)
Composer	The person or system authoring the composition
Context	Clinical context (care setting, timestamps, participants)
Content	Ordered list of ContentItem (Section or Entry)

Section

A grouping container within a composition, equivalent to a heading in a clinical document.

var historySection = new Section
{
    Name           = new DvText("History"),
    ArchetypeNodeId = "at0001",
    Items          = new List<ContentItem> { chiefComplaintObservation }
};

Entries

Four archetyped entry types represent the four kinds of clinical statement:

Class	openEHR code	Usage
Observation	OBSERVATION	Measurements, findings
Evaluation	EVALUATION	Assessments, diagnoses, goals
Instruction	INSTRUCTION	Orders, prescriptions
Action	ACTION	Performed procedures, dispensed medications

Observation example

var hrObservation = new Observation
{
    Name             = new DvText("Heart rate"),
    ArchetypeNodeId  = "openEHR-EHR-OBSERVATION.pulse.v2",
    Language         = new CodePhrase(new TerminologyId("ISO_639-1"), "en"),
    Encoding         = new CodePhrase(new TerminologyId("IANA_character-sets"), "UTF-8"),
    Subject          = new PartySelf(),
    Data = new History<ItemStructure>
    {
        Name   = new DvText("History"),
        Events = new List<Event<ItemStructure>>
        {
            new PointEvent<ItemStructure>
            {
                Name = new DvText("Any event"),
                Time = new DvDateTime(DateTimeOffset.UtcNow.ToString("o")),
                Data = new ItemTree
                {
                    Name  = new DvText("Tree"),
                    Items = new List<Item>
                    {
                        new Element
                        {
                            Name            = new DvText("Rate"),
                            ArchetypeNodeId = "at0004",
                            Value           = new DvQuantity { Magnitude = 72, Units = "/min" }
                        }
                    }
                }
            }
        }
    }
};