> ## Documentation Index
> Fetch the complete documentation index at: https://docs.clinikapi.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Documents

> Create structured clinical documents with sections — discharge summaries, care plans, referral letters.

# Documents

Documents (FHIR Composition) are structured clinical documents with titled sections. They're used for discharge summaries, referral letters, care plans, and other multi-section clinical documents.

## Create a Document

```ts theme={null}
const { data: doc } = await clinik.documents.create({
  status: 'final',
  type: 'discharge-summary',
  category: ['clinical', 'inpatient'],
  patientId: 'pt_abc123',
  encounterId: 'enc_xyz789',
  practitionerId: 'prac_def456',
  title: 'Discharge Summary - Jane Doe - Jan 15, 2025',
  date: '2025-01-15',
  confidentiality: 'N',
  attester: [{
    mode: 'professional',
    time: '2025-01-15T16:00:00Z',
    partyId: 'prac_attending',
  }],
  custodianId: 'org_hospital',
  event: [{
    code: [{ code: 'inpatient-stay', display: 'Inpatient Stay' }],
    period: { start: '2025-01-12', end: '2025-01-15' },
  }],
  sections: [
    {
      title: 'Chief Complaint',
      code: 'chief-complaint',
      text: 'Patient admitted for evaluation of acute chest pain.',
    },
    {
      title: 'Hospital Course',
      code: 'hospital-course',
      text: 'Cardiac workup negative. Discharged in stable condition.',
      authorId: 'prac_resident',  // Resident wrote this section
    },
    {
      title: 'Discharge Medications',
      code: 'medications',
      text: 'Continue aspirin 81mg daily, atorvastatin 20mg daily.',
      resourceIds: ['rx_aspirin', 'rx_statin'],
    },
    {
      title: 'Follow-up',
      code: 'follow-up',
      text: 'PCP: 1 week. Cardiology: 4 weeks.',
    },
  ],
});
```

## Nested Sections

Sections can contain sub-sections for complex documents:

```ts theme={null}
sections: [
  {
    title: 'Physical Examination',
    code: 'physical-exam',
    text: 'General examination findings.',
    sections: [
      {
        title: 'Cardiovascular',
        code: 'cardiovascular',
        text: 'Regular rate and rhythm. No murmurs, gallops, or rubs.',
      },
      {
        title: 'Respiratory',
        code: 'respiratory',
        text: 'Clear to auscultation bilaterally. No wheezes or crackles.',
      },
      {
        title: 'Neurological',
        code: 'neurological',
        text: 'Alert and oriented x3. Cranial nerves II-XII intact.',
      },
    ],
  },
]
```

## Document Attestation

Track who attested to the document's accuracy:

```ts theme={null}
attester: [
  {
    mode: 'professional',
    time: '2025-01-15T16:00:00Z',
    partyId: 'prac_attending',
  },
  {
    mode: 'legal',
    time: '2025-01-15T17:00:00Z',
    partyId: 'prac_chief_medical_officer',
  },
]
```

| Mode           | Description                         |
| -------------- | ----------------------------------- |
| `personal`     | Attested by the individual          |
| `professional` | Attested in a professional capacity |
| `legal`        | Legally attested                    |
| `official`     | Officially attested                 |

## Document Relationships

Link documents to other compositions they replace or append:

```ts theme={null}
// Create an amended version
const { data } = await clinik.documents.create({
  status: 'amended',
  type: 'discharge-summary',
  patientId: 'pt_abc123',
  practitionerId: 'prac_def456',
  title: 'Discharge Summary - Amended',
  relatesTo: [{
    code: 'replaces',
    targetId: 'doc_original_001',
  }],
  sections: [/* ... */],
});
```

## Clinical Events

Document the clinical services being described:

```ts theme={null}
event: [
  {
    code: [{ code: 'surgical-procedure', display: 'Surgical Procedure' }],
    period: { start: '2025-01-14T08:00:00Z', end: '2025-01-14T11:30:00Z' },
    detailIds: ['proc_knee_replacement'],
  },
]
```

## Document Types

| Type                  | Description                      |
| --------------------- | -------------------------------- |
| `discharge-summary`   | Hospital discharge documentation |
| `referral-letter`     | Referral to another provider     |
| `care-plan`           | Patient care plan                |
| `operative-report`    | Surgical operation report        |
| `transfer-summary`    | Patient transfer documentation   |
| `consultation-report` | Specialist consultation report   |

## Confidentiality Levels

| Code | Level           | Description                |
| ---- | --------------- | -------------------------- |
| `N`  | Normal          | Standard clinical document |
| `R`  | Restricted      | Limited access             |
| `V`  | Very Restricted | Highly sensitive           |

## Update a Document

```ts theme={null}
await clinik.documents.update('doc_abc123', {
  status: 'amended',
  attester: [{
    mode: 'professional',
    time: new Date().toISOString(),
    partyId: 'prac_attending',
  }],
  sections: [
    {
      title: 'Addendum',
      code: 'addendum',
      text: 'Patient called post-discharge reporting mild nausea.',
    },
  ],
});
```

## Search Documents

```ts theme={null}
const { data } = await clinik.documents.search({
  patientId: 'pt_abc123',
  type: 'discharge-summary',
  status: 'final',
  sort: '-date',
});
```

## Documents vs Notes

| Resource | FHIR Type         | Structure                | Use Case                        |
| -------- | ----------------- | ------------------------ | ------------------------------- |
| Note     | DocumentReference | Single content block     | Progress notes, SOAP notes      |
| Document | Composition       | Multiple titled sections | Discharge summaries, care plans |