Canadian Baseline
1.1.0 - CI Build
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
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.
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.
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:
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:
The following are example usage scenarios for the DocumentReference profile.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
subject | S | 0..1 | Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) | Who/what is the subject of the 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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | |
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() | |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() | |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DocumentReference
Summary
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
subject | S | 0..1 | Reference(Patient Profile | Practitioner Profile (General) | Device Profile (Implantable)) | Who/what is the subject of the 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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 |
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
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 |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | |
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() | |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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 | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | PractitionerSpecialtyhttps://fhir.infoway-inforoute.ca/ValueSet/practitionerspecialty from this IG |
Id | Grade | Path(s) | Details | Requirements |
ca-baseline-documentreference-1 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() | |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from DocumentReference
Summary
Must-Support: 11 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron