International Patient Access
1.0.0-preview - STU1 International flag

International Patient Access, published by HL7 International - Patient Care Work Group. This is not an authorized publication; it is the continuous build for version 1.0.0-preview). This version is based on the current content of https://github.com/HL7/fhir-ipa/ and changes regularly. See the Directory of published versions

Resource Profile: IPA-DocumentReference

Official URL: http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-documentreference Version: 1.0.0-preview
Active as of 2022-08-02 Computable Name: IPADocumentReference

Copyright/Legal: Used by permission of HL7 International all rights reserved Creative Commons License

Minimum expectations for a DocumentReference resource when accessed via a International Patient Access API

Mandatory and Must Support Data Elements

The following data elements must always be present (in other words, mandatory resource properties with a minimum cardinality of 1) or must be supported (Must Support definition). Servers cannot restrict access to mandatory elements when authorizing an application. However, servers may choose to provide additional information or may be required to do so by national or other profiles that apply to the server’s context.

Each Immunization SHALL have:

  • a status
  • a patient
  • one or more documents referenced (content) which is either a URL where the data can be found or inline data or both
  • the MIME type (i.e. contentType) of the document

Applications must also support:

  • a code describing the type of document
  • one or more category codes used to group document types
  • date and time the reference was created
  • one or more authors
  • a code identifying the specific details about the format of the document — over and above the content’s MIME type
  • the patient encounter that is being referenced
  • clinically relevant date

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codecurrent | superseded | entered-in-error
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S0..*CodeableConceptCategorization of document
... date S0..1instantWhen this document reference was created
... author S0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... content S1..*BackboneElementDocument referenced
.... attachment SC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S1..1codeMime type of the content, with charset etc.
..... data S0..1base64BinaryData inline, base64ed
..... url S0..1urlUri where the data can be found
.... format S0..1CodingFormat/content rules for the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... period S0..1PeriodTime of service that is being documented

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
ipa-doc-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... category SΣ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(IPA-Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ1..1codeMime 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 S0..1base64BinaryData inline, base64ed
..... url SΣ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... period SΣ0..1PeriodTime of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
ipa-doc-1errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(IPA-Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime 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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S0..1base64BinaryData inline, base64ed
..... url SΣ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePath(s)DetailsRequirements
ipa-doc-1errorDocumentReference.content.attachmentDocumentReference.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 DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codecurrent | superseded | entered-in-error
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S0..*CodeableConceptCategorization of document
... date S0..1instantWhen this document reference was created
... author S0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... content S1..*BackboneElementDocument referenced
.... attachment SC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S1..1codeMime type of the content, with charset etc.
..... data S0..1base64BinaryData inline, base64ed
..... url S0..1urlUri where the data can be found
.... format S0..1CodingFormat/content rules for the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... period S0..1PeriodTime of service that is being documented

doco Documentation for this format

Constraints

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

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... category SΣ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(IPA-Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ1..1codeMime 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 S0..1base64BinaryData inline, base64ed
..... url SΣ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... period SΣ0..1PeriodTime of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(IPA-Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime 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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S0..1base64BinaryData inline, base64ed
..... url SΣ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

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

 

Other representations of profile: CSV, Excel, Schematron