Electronic Case Reporting (eCR)
3.0.0-ballot - STU 3 - Ballot United States of America flag

Electronic Case Reporting (eCR), published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 3.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/case-reporting/ and changes regularly. See the Directory of published versions

Resource Profile: RR DocumentReference

Official URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-documentreference Version: 3.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: RRDocumentReference
Other Identifiers: OID:2.16.840.1.113883.4.642.40.46.42.16

This profile represents external resources such as a text guidance, link to access forms for additional reporting needs, additional testing and/or laboratory testing needs, treatment and/or prevention resources, Public Health Agency contact information and general additional resources.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code (USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept (USCDI) Kind of document (LOINC if possible)
Binding: USCoreDocumentReferenceType (6.1.0) (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
Additional BindingsPurpose
USCoreClinicalNoteType (6.1.0) Min Binding
... Slices for category SΣ 1..* CodeableConcept External Resource Type
Slice: Unordered, Open by pattern:$this
Binding: External Resource Type (eCR) (extensible): External Resource Type
.... category:uscore Σ 0..* CodeableConcept (USCDI) Categorization of document
Binding: USCoreDocumentReferenceCategory (6.1.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... subject SΣ 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document
... date SΣ 0..1 instant (USCDI) When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) | US Core Patient Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core RelatedPerson Profile | Device) (USCDI) Who and/or what authored the document
... description SΣ 1..1 string External resource description
... content SΣ 1..* BackboneElement (USCDI) Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment (USCDI) Where to access the document
Constraints: us-core-6
..... contentType SΣ 0..1 code (USCDI) 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 (USCDI) Data inline, base64ed
..... url SΣC 0..1 url (USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding (USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement (USCDI) Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(6.1.0)) (USCDI) Context of the document content
.... period SΣ 0..1 Period (USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.type Base required US Core DocumentReference Type 📍6.1.0 US Core v6.1
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12
DocumentReference.category:uscore Base required US Core DocumentReference Category 📍6.1.0 US Core v6.1
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base extensible DocumentReference Format Code Set 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
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 USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... category 1..* CodeableConcept External Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type
... subject 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier (USCDI) Other identifiers for the document
... status ?!SΣ 1..1 code (USCDI) 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 (USCDI) Kind of document (LOINC if possible)
Binding: USCoreDocumentReferenceType (6.1.0) (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
Additional BindingsPurpose
USCoreClinicalNoteType (6.1.0) Min Binding
... Slices for category SΣ 1..* CodeableConcept External Resource Type
Slice: Unordered, Open by pattern:$this
Binding: External Resource Type (eCR) (extensible): External Resource Type
.... category:uscore Σ 0..* CodeableConcept (USCDI) Categorization of document
Binding: USCoreDocumentReferenceCategory (6.1.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... subject SΣ 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document
... date SΣ 0..1 instant (USCDI) When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) | US Core Patient Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core RelatedPerson Profile | Device) (USCDI) Who and/or what authored the document
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) 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 SΣ 1..1 string External resource 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 (USCDI) 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 (USCDI) Where to access the document
Constraints: us-core-6
..... 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 (USCDI) 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.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary (USCDI) Data inline, base64ed
..... url SΣC 0..1 url (USCDI) 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 (USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement (USCDI) 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..1 Reference(US Core Encounter Profile(6.1.0)) (USCDI) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
.... period SΣ 0..1 Period (USCDI) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base required US Core DocumentReference Type 📍6.1.0 US Core v6.1
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12
DocumentReference.category:uscore Base required US Core DocumentReference Category 📍6.1.0 US Core v6.1
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.content.​format Base extensible DocumentReference Format Code Set 📦4.0.1 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📍3.0.0 THO v6.5
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
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 USCoreDocumentReferenceProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 3

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code (USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept (USCDI) Kind of document (LOINC if possible)
Binding: USCoreDocumentReferenceType (6.1.0) (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
Additional BindingsPurpose
USCoreClinicalNoteType (6.1.0) Min Binding
... Slices for category SΣ 1..* CodeableConcept External Resource Type
Slice: Unordered, Open by pattern:$this
Binding: External Resource Type (eCR) (extensible): External Resource Type
.... category:uscore Σ 0..* CodeableConcept (USCDI) Categorization of document
Binding: USCoreDocumentReferenceCategory (6.1.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... subject SΣ 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document
... date SΣ 0..1 instant (USCDI) When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) | US Core Patient Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core RelatedPerson Profile | Device) (USCDI) Who and/or what authored the document
... description SΣ 1..1 string External resource description
... content SΣ 1..* BackboneElement (USCDI) Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment (USCDI) Where to access the document
Constraints: us-core-6
..... contentType SΣ 0..1 code (USCDI) 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 (USCDI) Data inline, base64ed
..... url SΣC 0..1 url (USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding (USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement (USCDI) Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(6.1.0)) (USCDI) Context of the document content
.... period SΣ 0..1 Period (USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.type Base required US Core DocumentReference Type 📍6.1.0 US Core v6.1
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12
DocumentReference.category:uscore Base required US Core DocumentReference Category 📍6.1.0 US Core v6.1
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base extensible DocumentReference Format Code Set 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
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()

Differential View

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... category 1..* CodeableConcept External Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type
... subject 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(6.1.0) RR Document Reference
... 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
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:priority S 1..* CodeableConcept Reportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier (USCDI) Other identifiers for the document
... status ?!SΣ 1..1 code (USCDI) 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 (USCDI) Kind of document (LOINC if possible)
Binding: USCoreDocumentReferenceType (6.1.0) (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
Additional BindingsPurpose
USCoreClinicalNoteType (6.1.0) Min Binding
... Slices for category SΣ 1..* CodeableConcept External Resource Type
Slice: Unordered, Open by pattern:$this
Binding: External Resource Type (eCR) (extensible): External Resource Type
.... category:uscore Σ 0..* CodeableConcept (USCDI) Categorization of document
Binding: USCoreDocumentReferenceCategory (6.1.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
... subject SΣ 1..1 Reference(US Public Health Patient) (USCDI) Who/what is the subject of the document
... date SΣ 0..1 instant (USCDI) When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile(6.1.0) S | US Core Organization Profile(6.1.0) | US Core Patient Profile(6.1.0) | US Core PractitionerRole Profile(6.1.0) | US Core RelatedPerson Profile | Device) (USCDI) Who and/or what authored the document
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) 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 SΣ 1..1 string External resource 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 (USCDI) 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 (USCDI) Where to access the document
Constraints: us-core-6
..... 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 (USCDI) 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.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary (USCDI) Data inline, base64ed
..... url SΣC 0..1 url (USCDI) 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 (USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement (USCDI) 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..1 Reference(US Core Encounter Profile(6.1.0)) (USCDI) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
.... period SΣ 0..1 Period (USCDI) 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base required US Core DocumentReference Type 📍6.1.0 US Core v6.1
DocumentReference.category Base extensible External Resource Type (eCR) 📦1 us.cdc.phinvads v0.12
DocumentReference.category:uscore Base required US Core DocumentReference Category 📍6.1.0 US Core v6.1
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.content.​format Base extensible DocumentReference Format Code Set 📦4.0.1 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📍3.0.0 THO v6.5
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()
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 USCoreDocumentReferenceProfile

Summary

Mandatory: 3 elements
Must-Support: 2 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Maturity: 3

 

Other representations of profile: CSV, Excel, Schematron