US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 8.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-adi-documentreference | Version: 8.0.0-ballot | |||
Standards status: Trial-use | Maturity Level: 3 | Computable Name: USCoreADIDocumentReferenceProfile | ||
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.4 | ||||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License |
The US Core ADI DocumentReference Profile inherits from the FHIR DocumentReference resource; refer to it for scope and usage definitions. This profile and the US Core Observation ADI Documentation Profile meet the U.S. Core Data for Interoperability (USCDI) Advance Directive Observation Data Element requirements. It sets minimum expectations for searching and fetching patient Advance Directive Information (ADI) documents using the DocumentReference resource. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. In addition to the document contents, it communicates the type of advance directive document, the author, the verifier, and other properties. To represent whether advance directive documents exist for a patient, see the US Core Observation ADI Documentation Profile. This profile sets minimum expectations for searching and fetching patient ADI documents using the DocumentReference resource. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.
This page has new content for US Core Version 8.0.0
Example Usage Scenarios:
The following are example usage scenarios for the US Core ADI DocumentReference profile:
The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.
Each DocumentReference Must Have:
Each DocumentReference Must Support:
Profile Specific Implementation Guidance:
DocumentReference.attachment.url
or the content as inline base64 encoded data using DocumentReference.attachment.data
.
content.url
may refer to a FHIR Binary Resource (i.e., [base]/Binary/[id]), FHIR Document Bundle (i.e., [base]/Bundle/[id], or another endpoint.
DocumentReference.content
element repetitions, these SHALL all represent the same document in different formats or attachment metadata. The content element SHALL NOT contain different versions of the same content. For version handling, use multiple DocumentReferences with DocumentReference.relatesTo
.DocumentReference.custodian
or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who
or Provenance.agent.onBehalfOf
.
Encounter.serviceProvider
.Usage:
Changes since version 7.0.0:
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 | A reference to a document | |
Slices for extension | Content/Rules for all slices | |||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time |
identifier | S | 0..* | Identifier | Other identifiers for the document |
status | S | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type |
Slices for category | S | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this |
category:adi | S | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
subject | S | 1..1 | Reference(US Core Patient Profile S | Practitioner | Group | Device) | Who/what is the subject of the document |
date | S | 0..1 | instant | When this document reference was created |
author | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) | Who/what authenticated the document |
content | S | 1..* | BackboneElement | Document referenced |
attachment | SC | 1..1 | Attachment | Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
contentType | S | 0..1 | code | Mime type of the content, with charset etc. |
data | SC | 0..1 | base64Binary | Data inline, base64ed |
url | SC | 0..1 | url | Uri where the data can be found |
format | S | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | |
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | |
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | |
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | 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 | A reference to a document | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Other identifiers for the document |
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type |
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:adi | SΣ | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
date | SΣ | 0..1 | instant | When this document reference was created |
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(US Core Practitioner Profile) | Who/what authenticated the document |
content | SΣ | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
contentType | SΣ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png |
data | SC | 0..1 | base64Binary | Data inline, base64ed |
url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | |
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | |
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | |
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | 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 | A reference to a document | |||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:adi | SΣ | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Practitioner | Group | Device) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document | ||||
authenticator | S | 0..1 | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) | Who/what authenticated the document | ||||
custodian | 0..1 | Reference(Organization) | 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 | SΣ | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | SΣ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
data | SC | 0..1 | base64Binary | Data inline, base64ed | ||||
url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) | ||||
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 | 0..* | Reference(Encounter | EpisodeOfCare) | 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 | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | 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 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | ||||
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.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes | ||||
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 | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements
Must-Support: 16 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 3
Differential View
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
Slices for extension | Content/Rules for all slices | |||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time |
identifier | S | 0..* | Identifier | Other identifiers for the document |
status | S | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type |
Slices for category | S | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this |
category:adi | S | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
subject | S | 1..1 | Reference(US Core Patient Profile S | Practitioner | Group | Device) | Who/what is the subject of the document |
date | S | 0..1 | instant | When this document reference was created |
author | S | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) | Who/what authenticated the document |
content | S | 1..* | BackboneElement | Document referenced |
attachment | SC | 1..1 | Attachment | Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
contentType | S | 0..1 | code | Mime type of the content, with charset etc. |
data | SC | 0..1 | base64Binary | Data inline, base64ed |
url | SC | 0..1 | url | Uri where the data can be found |
format | S | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | |
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | |
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | |
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | 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 | A reference to a document | |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
identifier | SΣ | 0..* | Identifier | Other identifiers for the document |
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type |
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
category:adi | SΣ | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets |
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
date | SΣ | 0..1 | instant | When this document reference was created |
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(US Core Practitioner Profile) | Who/what authenticated the document |
content | SΣ | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
contentType | SΣ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png |
data | SC | 0..1 | base64Binary | Data inline, base64ed |
url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | |
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | |
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | |
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
authenticationTime | S | 0..1 | dateTime | Authentication Time" URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Advance Directives Content Type (extensible): Advance Directives Content Type | ||||
Slices for category | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by value:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:adi | SΣ | 0..* | CodeableConcept | Categorization of ADI document" Binding: Advance Healthcare Directive Categories Grouper (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile S | Practitioner | Group | Device) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document | ||||
authenticator | S | 0..1 | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) | Who/what authenticated the document | ||||
custodian | 0..1 | Reference(Organization) | 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 | SΣ | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | SΣ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
data | SC | 0..1 | base64Binary | Data inline, base64ed | ||||
url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible) | ||||
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 | 0..* | Reference(Encounter | EpisodeOfCare) | 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 | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | 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 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | extensible | AdvanceDirectivesContentType http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1099.57 | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:adi | required | AdvanceHealthcareDirectiveCategoriesGrouper http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1115.25 | ||||
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.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes | ||||
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 | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements
Must-Support: 16 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.
The following search parameters and search parameter combinations SHALL be supported:
SHALL support both read DocumentReference by id
AND DocumentReference search using the _id
search parameter:
GET [base]/DocumentReference/[id]
or GET [base]/DocumentReference?_id=[id]
Example:
Implementation Notes: Fetches a single DocumentReference. The document itself is represented as a base64 encoded binary data
element or retrieved using the link provided by the resource. If the document is a relative link to a [Binary] resource like a resource reference, it can be subsequently retrieved using: GET [base]/Binary/[id]
. (how to search by the logical id of the resource)
SHALL support searching for all documentreferences for a patient using the patient
search parameter:
GET [base]/DocumentReference?patient={Type/}[id]
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient. See the implementation notes above for how to access the actual document. (how to search by reference)
SHALL support searching using the combination of the patient
and category
search parameters:
GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical-note
. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
date
(e.g.date=[date]&date=[date]]&...
)GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical=note
and date. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)
SHALL support searching using the combination of the patient
and type
search parameters:
GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)
The following search parameter combinations SHOULD be supported:
patient
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and status. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)
patient
and type
and period
search parameters:
period
comparators: gt,lt,ge,le
period
(e.g.period=[date]&period=[date]]&...
)GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and period. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)