Canadian Baseline
1.1.0 - CI Build Canada flag

Canadian Baseline, published by HL7 Canada - FHIR Implementation Work Group. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Canada/ca-baseline/ and changes regularly. See the Directory of published versions

Resource Profile: Document Reference Profile

Official URL: http://hl7.org/fhir/ca/baseline/StructureDefinition/profile-documentreference Version: 1.1.0
Draft as of 2020-10-21 Computable Name: DocumentReferenceProfile

Proposed constraints on the DocumentReference resource for the minimal set of data required to reference to a document of any kind for any purpose.

CA Core DocumentReference Profile

This DocumentReference profile sets minimum expectations for mandatory core elements, constraints and value sets required to provide metadata about the document of any kind so that the document can be published, discovered and managed.

This profile defines core localisation concepts for use in an Canadian context.

Mandatory Data Elements

All elements or attributes defined in FHIR have cardinality as part of their definition - a minimum number of required appearances and a maximum number.

Most elements in FHIR specification have a minimum cardinality of 0, which means that they may be missing from a resource when it is exchanged between systems.

Required elements:

  • status of the refence
  • document referenced

Must Support Data Elements

Some elements are labeled as MustSupport meaning that implementations that produce or consume resources SHALL provide "support" for the element in some meaningful way (see Must Support definition).

Following elements are marked as Must Support in the Canadian DocumentReference profile to aid record matching in databases.

Must Support elements:

  • master version identifier
  • kind of document
  • categorization of document
  • subject of the document
  • document author
  • document authenticator
  • organization which maintains the document
  • the document itself or URL
  • context of the document content
  • practice settings
  • patient demographics

Usage Note

The following are example usage scenarios for the DocumentReference profile.

  • Publishing a new document. This can be done using the IHE MHD Provide Document Bundle [ITI-65] transaction that carries both the document and its metadata.
  • Querying the document repository for specific document(s) matching various metadata parameters. This is similar to the IHE MHD Find Document References [ITI-67] transaction.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... masterIdentifier S 0..1 Identifier Master Version Specific Identifier
... type S 0..1 CodeableConcept Kind of document (LOINC if possible)
... category S 0..* CodeableConcept Categorization of document
... author S 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... content
.... attachment SC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
... context
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) Who/what is the subject of the document
... author SΣ 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... content Σ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
... context Σ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) Who/what is the subject of the document
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... masterIdentifier S 0..1 Identifier Master Version Specific Identifier
... type S 0..1 CodeableConcept Kind of document (LOINC if possible)
... category S 0..* CodeableConcept Categorization of document
... author S 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... content
.... attachment SC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
... context
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) Who/what is the subject of the document
... author SΣ 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... content Σ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
... context Σ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference DocumentReference Profile
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ 0..1 Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) Who/what is the subject of the document
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile | Device Profile (Implantable) | Patient Profile) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner Profile (General) | PractitionerRole Profile (General) | Organization Profile) Who/what authenticated the document
... custodian S 0..1 Reference(Organization Profile) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
ca-baseline-documentreference-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Encounter Profile) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S 0..1 CodeableConcept PractitionerSpecialty
Binding: PractitionerSpecialty (preferred): Defines the clinical, medical, surgical or other healthcare-related service specialty of a practitioner who interacts, treats or provides such services to or for a patient.

.... sourcePatientInfo S 0..1 Reference(Patient Profile) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingpreferredPractitionerSpecialty
https://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty
from this IG

Constraints

IdGradePath(s)DetailsRequirements
ca-baseline-documentreference-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()

 

Other representations of profile: CSV, Excel, Schematron