PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2 United States of America flag

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 International / Patient Empowerment. This guide is not an authorized publication; it is the continuous build for version 2.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-pacio-adi/ and changes regularly. See the Directory of published versions

Resource Profile: ADIDocumentReference - Detailed Descriptions

Active as of 2024-07-14

Definitions for the ADI-DocumentReference resource profile.

Guidance on how to interpret the contents of this table can be found here

0. DocumentReference
2. DocumentReference.extension
SlicingThis element introduces a set of slices on DocumentReference.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
  • value @ url
  • 4. DocumentReference.extension:DocumentRevokeStatusExtension
    Slice NameDocumentRevokeStatusExtension
    Control0..1
    TypeExtension(Revoke Status) (Extension Type: code)
    Must Supporttrue
    6. DocumentReference.docStatus
    BindingThe codes SHALL be taken from ADI Document Reference Status
    (required to http://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVS)
    8. DocumentReference.category
    BindingUnless not suitable, these codes SHALL be taken from US Core DocumentReference Category
    (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category)
    10. DocumentReference.date
    Control1..?
    12. DocumentReference.author
    TypeReference(US Core Practitioner Profile, US Core Organization Profile, US Core Patient Profile)
    14. DocumentReference.custodian
    TypeReference(US Core Organization Profile)
    Must Supporttrue
    16. DocumentReference.content
    18. DocumentReference.content.attachment
    20. DocumentReference.content.attachment.contentType
    Control1..?
    22. DocumentReference.content.attachment.creation
    Control1..?
    Must Supporttrue

    Guidance on how to interpret the contents of this table can be found here

    0. DocumentReference
    Definition

    -


    A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

    ShortA reference to a document
    Comments

    -


    Usually, this is used for documents other than those defined by FHIR.

    Control0..*
    Is Modifierfalse
    Must Supportfalse
    Summaryfalse
    Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
    dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
    dom-6: A resource should have narrative for robust management (text.`div`.exists())
    2. DocumentReference.implicitRules
    Definition

    A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

    ShortA set of rules under which this content was created
    Comments

    Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

    Control0..1
    Typeuri
    Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
    Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
    Summarytrue
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    4. DocumentReference.extension
    Definition

    An Extension


    May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

    ShortExtensionAdditional content defined by implementations
    Comments

    There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

    Control0..*
    TypeExtension
    Is Modifierfalse
    Summaryfalse
    Alternate Namesextensions, user content
    Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
    ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
    SlicingThis element introduces a set of slices on DocumentReference.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
    • value @ url
    • 6. DocumentReference.extension:DocumentRevokeStatusExtension
      Slice NameDocumentRevokeStatusExtension
      Definition

      The Advance Directive document revoke status.

      ShortRevoke Status
      Control0..1
      This element is affected by the following invariants: ele-1
      TypeExtension(Revoke Status) (Extension Type: code)
      Is Modifierfalse
      Must Supporttrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      8. DocumentReference.modifierExtension
      Definition

      May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

      Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

      ShortExtensions that cannot be ignored
      Comments

      There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

      Control0..*
      TypeExtension
      Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
      Summaryfalse
      Requirements

      Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

      Alternate Namesextensions, user content
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
      10. DocumentReference.identifier
      Definition

      Other identifiers associated with the document, including version independent identifiers.

      Short(USCDI) Other identifiers for the documentOther identifiers for the document
      NoteThis is a business identifier, not a resource identifier (see discussion)
      Control0..*
      TypeIdentifier
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      12. DocumentReference.status
      Definition

      The status of this document reference.

      Short(USCDI) current | superseded | entered-in-errorcurrent | superseded | entered-in-error
      Comments

      This is the status of the DocumentReference object, which might be independent from the docStatus element.

      This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

      Control1..1
      BindingThe codes SHALL be taken from DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
      (required to http://hl7.org/fhir/ValueSet/document-reference-status)
      Typecode
      Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      14. DocumentReference.docStatus
      Definition

      The status of the underlying document.

      Shortpreliminary | final | amended | entered-in-error
      Comments

      The document that is pointed to might be in various lifecycle states.

      Control0..1
      BindingThe codes SHALL be taken from ADI Document Reference Statushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1
      (required to http://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVS)
      Typecode
      Is Modifierfalse
      Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      16. DocumentReference.type
      Definition

      Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

      Short(USCDI) Kind of document (LOINC if possible)Kind of document (LOINC if possible)
      Comments

      Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

      Control10..1
      BindingThe codes SHALL be taken from The codes SHOULD be taken from US Core DocumentReference Typehttp://hl7.org/fhir/ValueSet/c80-doc-typecodes
      (required to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type)

      All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'


      Precise type of clinical document.

      Additional BindingsPurpose
      US Core Clinical Note TypeMin Binding
      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      18. DocumentReference.category
      Definition

      A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

      Short(USCDI) Categorization of documentCategorization of document
      Comments

      Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

      Control10..*
      BindingUnless not suitable, these codes SHALL be taken from For example codes, see US Core DocumentReference Categoryhttp://hl7.org/fhir/ValueSet/document-classcodes
      (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category)
      TypeCodeableConcept
      Is Modifierfalse
      Must Supporttrue
      Summarytrue
      Alternate Namesclaxs
      Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
      SlicingThis element introduces a set of slices on DocumentReference.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
      • pattern @ $this
      • 20. DocumentReference.category:uscore
        Slice Nameuscore
        Definition

        A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

        Short(USCDI) Categorization of documentCategorization of document
        Comments

        Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

        Control0..*
        BindingThe codes SHALL be taken from For example codes, see US Core DocumentReference Categoryhttp://hl7.org/fhir/ValueSet/document-classcodes
        (required to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category)

        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


        High-level kind of a clinical document at a macro level.

        TypeCodeableConcept
        Is Modifierfalse
        Summarytrue
        Alternate Namesclaxs
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        22. DocumentReference.subject
        Definition

        Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

        Short(USCDI) Who/what is the subject of the documentWho/what is the subject of the document
        Control10..1
        TypeReference(US Core Patient Profile, Patient, Practitioner, Group, Device)
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        24. DocumentReference.date
        Definition

        When the document reference was created.

        Short(USCDI) When this document reference was createdWhen this document reference was created
        Comments

        Referencing/indexing time is used for tracking, organizing versions and searching.

        Control10..1
        Typeinstant
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Alternate Namesindexed
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        26. DocumentReference.author
        Definition

        Identifies who is responsible for adding the information to the document.

        Short(USCDI) Who and/or what authored the documentWho and/or what authored the document
        Comments

        Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

        Control0..*
        TypeReference(US Core Practitioner Profile, US Core Organization Profile, US Core Patient Profile, Practitioner, PractitionerRole, Organization, Device, Patient, RelatedPerson)
        Is Modifierfalse
        Must Supporttrue
        Must Support TypesReference(US Core Practitioner Profile)
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        28. DocumentReference.custodian
        Definition

        Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

        ShortOrganization which maintains the document
        Comments

        Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

        Control0..1
        TypeReference(US Core Organization Profile, Organization)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        30. DocumentReference.content
        Definition

        The document and format referenced. There may be multiple content element repetitions, each with a different format.

        Short(USCDI) Document referencedDocument referenced
        Control1..*
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        32. DocumentReference.content.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        34. DocumentReference.content.attachment
        Definition

        The document or URL of the document along with critical metadata to prove content has integrity.

        Short(USCDI) Where to access the documentWhere to access the document
        Control1..1
        TypeAttachment
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. (url.exists() or data.exists())
        36. DocumentReference.content.attachment.contentType
        Definition

        Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.

        Short(USCDI) Mime type of the content, with charset etc.Mime type of the content, with charset etc.
        Control10..1
        BindingThe codes SHALL be taken from Mime Typeshttp://hl7.org/fhir/ValueSet/mimetypes|4.0.1
        (required to http://hl7.org/fhir/ValueSet/mimetypes|4.0.1)

        The mime type of an attachment. Any valid mime type is allowed.

        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        Processors of the data need to be able to know how to interpret the data.

        Example<br/><b>General</b>:text/plain; charset=UTF-8, image/png
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        38. DocumentReference.content.attachment.data
        Definition

        The actual data of the attachment - a sequence of bytes, base64 encoded.

        Short(USCDI) Data inline, base64edData inline, base64ed
        Comments

        The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.

        Control0..1
        This element is affected by the following invariants: us-core-6
        Typebase64Binary
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summaryfalse
        Requirements

        The data needs to able to be transmitted inline.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        40. DocumentReference.content.attachment.url
        Definition

        A location where the data can be accessed.

        Short(USCDI) Uri where the data can be foundUri where the data can be found
        Comments

        If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.

        Control0..1
        This element is affected by the following invariants: us-core-6
        Typeurl
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        The data needs to be transmitted by reference.

        Example<br/><b>General</b>:http://www.acme.com/logo-small.png
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        42. DocumentReference.content.attachment.creation
        Definition

        The date that the attachment was first created.

        ShortDate attachment was first created
        Control10..1
        TypedateTime
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Must Supporttrue
        Summarytrue
        Requirements

        This is often tracked as an integrity issue for use of the attachment.

        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        44. DocumentReference.content.format
        Definition

        An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

        Short(USCDI) Format/content rules for the documentFormat/content rules for the document
        Comments

        Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

        Control0..1
        BindingUnless not suitable, these codes SHALL be taken from The codes SHOULD be taken from DocumentReferenceFormatCodeSethttp://hl7.org/fhir/ValueSet/formatcodes
        (extensible to http://hl7.org/fhir/ValueSet/formatcodes)
        TypeCoding
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        46. DocumentReference.context
        Definition

        The clinical context in which the document was prepared.

        Short(USCDI) Clinical context of documentClinical context of document
        Comments

        These values are primarily added to help with searching for interesting/relevant documents.

        Control0..1
        TypeBackboneElement
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        48. DocumentReference.context.modifierExtension
        Definition

        May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

        Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

        ShortExtensions that cannot be ignored even if unrecognized
        Comments

        There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

        Control0..*
        TypeExtension
        Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
        Summarytrue
        Requirements

        Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

        Alternate Namesextensions, user content, modifiers
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        50. DocumentReference.context.encounter
        Definition

        Describes the clinical encounter or type of care that the document content is associated with.

        Short(USCDI) Context of the document contentContext of the document content
        Control0..1*
        TypeReference(US Core Encounter Profile, Encounter, EpisodeOfCare)
        Is Modifierfalse
        Must Supporttrue
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        52. DocumentReference.context.period
        Definition

        The time period over which the service that is described by the document was provided.

        Short(USCDI) Time of service that is being documentedTime of service that is being documented
        Control0..1
        TypePeriod
        Is Modifierfalse
        Must Supporttrue
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))

        Guidance on how to interpret the contents of this table can be found here

        0. DocumentReference
        Definition

        -

        ShortA reference to a document
        Comments

        -

        Control0..*
        Is Modifierfalse
        Must Supportfalse
        Summaryfalse
        Invariantsdom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty())
        dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label (contained.meta.security.empty())
        dom-6: A resource should have narrative for robust management (text.`div`.exists())
        2. DocumentReference.id
        Definition

        The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

        ShortLogical id of this artifact
        Comments

        The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

        Control0..1
        Typeid
        Is Modifierfalse
        Summarytrue
        4. DocumentReference.meta
        Definition

        The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

        ShortMetadata about the resource
        Control0..1
        TypeMeta
        Is Modifierfalse
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        6. DocumentReference.implicitRules
        Definition

        A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

        ShortA set of rules under which this content was created
        Comments

        Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

        Control0..1
        Typeuri
        Is Modifiertrue because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summarytrue
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        8. DocumentReference.language
        Definition

        The base language in which the resource is written.

        ShortLanguage of the resource content
        Comments

        Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

        Control0..1
        BindingThe codes SHOULD be taken from CommonLanguages
        (preferred to http://hl7.org/fhir/ValueSet/languages)

        A human language.

        Additional BindingsPurpose
        AllLanguagesMax Binding
        Typecode
        Is Modifierfalse
        Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        10. DocumentReference.text
        Definition

        A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

        ShortText summary of the resource, for human interpretation
        Comments

        Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

        Control0..1
        TypeNarrative
        Is Modifierfalse
        Summaryfalse
        Alternate Namesnarrative, html, xhtml, display
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        12. DocumentReference.contained
        Definition

        These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

        ShortContained, inline Resources
        Comments

        This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

        Control0..*
        TypeResource
        Is Modifierfalse
        Summaryfalse
        Alternate Namesinline resources, anonymous resources, contained resources
        14. DocumentReference.extension
        Definition

        An Extension

        ShortExtension
        Control0..*
        TypeExtension
        Is Modifierfalse
        Summaryfalse
        Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
        ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
        SlicingThis element introduces a set of slices on DocumentReference.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
        • value @ url
        • 16. DocumentReference.extension:DocumentRevokeStatusExtension
          Slice NameDocumentRevokeStatusExtension
          Definition

          The Advance Directive document revoke status.

          ShortRevoke Status
          Control0..1
          This element is affected by the following invariants: ele-1
          TypeExtension(Revoke Status) (Extension Type: code)
          Is Modifierfalse
          Must Supporttrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          18. DocumentReference.modifierExtension
          Definition

          May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

          Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

          ShortExtensions that cannot be ignored
          Comments

          There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

          Control0..*
          TypeExtension
          Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
          Summaryfalse
          Requirements

          Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

          Alternate Namesextensions, user content
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
          20. DocumentReference.masterIdentifier
          Definition

          Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.

          ShortMaster Version Specific Identifier
          Comments

          CDA Document Id extension and root.

          Control0..1
          TypeIdentifier
          Is Modifierfalse
          Summarytrue
          Requirements

          The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          22. DocumentReference.identifier
          Definition

          Other identifiers associated with the document, including version independent identifiers.

          Short(USCDI) Other identifiers for the document
          NoteThis is a business identifier, not a resource identifier (see discussion)
          Control0..*
          TypeIdentifier
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          24. DocumentReference.status
          Definition

          The status of this document reference.

          Short(USCDI) current | superseded | entered-in-error
          Comments

          This is the status of the DocumentReference object, which might be independent from the docStatus element.

          This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

          Control1..1
          BindingThe codes SHALL be taken from DocumentReferenceStatus
          (required to http://hl7.org/fhir/ValueSet/document-reference-status)
          Typecode
          Is Modifiertrue because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Must Supporttrue
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          26. DocumentReference.docStatus
          Definition

          The status of the underlying document.

          Shortpreliminary | final | amended | entered-in-error
          Comments

          The document that is pointed to might be in various lifecycle states.

          Control0..1
          BindingThe codes SHALL be taken from ADI Document Reference Status
          (required to http://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVS)
          Typecode
          Is Modifierfalse
          Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          28. DocumentReference.type
          Definition

          Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

          Short(USCDI) Kind of document (LOINC if possible)
          Comments

          Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

          Control1..1
          BindingThe codes SHALL be taken from US Core DocumentReference Type
          (required to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type)

          All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

          Additional BindingsPurpose
          US Core Clinical Note TypeMin Binding
          TypeCodeableConcept
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          30. DocumentReference.category
          Definition

          A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

          Short(USCDI) Categorization of document
          Comments

          Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

          Control1..*
          BindingUnless not suitable, these codes SHALL be taken from US Core DocumentReference Category
          (extensible to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category)
          TypeCodeableConcept
          Is Modifierfalse
          Must Supporttrue
          Summarytrue
          Alternate Namesclaxs
          Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
          SlicingThis element introduces a set of slices on DocumentReference.category. The slices areUnordered and Open, and can be differentiated using the following discriminators:
          • pattern @ $this
          • 32. DocumentReference.category:uscore
            Slice Nameuscore
            Definition

            A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

            Short(USCDI) Categorization of document
            Comments

            Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

            Control0..*
            BindingThe codes SHALL be taken from US Core DocumentReference Category
            (required to http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category)

            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

            TypeCodeableConcept
            Is Modifierfalse
            Summarytrue
            Alternate Namesclaxs
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            34. DocumentReference.subject
            Definition

            Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

            Short(USCDI) Who/what is the subject of the document
            Control1..1
            TypeReference(US Core Patient Profile)
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            36. DocumentReference.date
            Definition

            When the document reference was created.

            Short(USCDI) When this document reference was created
            Comments

            Referencing/indexing time is used for tracking, organizing versions and searching.

            Control1..1
            Typeinstant
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Must Supporttrue
            Summarytrue
            Alternate Namesindexed
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            38. DocumentReference.author
            Definition

            Identifies who is responsible for adding the information to the document.

            Short(USCDI) Who and/or what authored the document
            Comments

            Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

            Control0..*
            TypeReference(US Core Practitioner Profile, US Core Organization Profile, US Core Patient Profile)
            Is Modifierfalse
            Must Supporttrue
            Must Support TypesReference(US Core Practitioner Profile)
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            40. DocumentReference.authenticator
            Definition

            Which person or organization authenticates that this document is valid.

            ShortWho/what authenticated the document
            Comments

            Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.

            Control0..1
            TypeReference(Practitioner, PractitionerRole, Organization)
            Is Modifierfalse
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            42. DocumentReference.custodian
            Definition

            Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

            ShortOrganization which maintains the document
            Comments

            Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

            Control0..1
            TypeReference(US Core Organization Profile)
            Is Modifierfalse
            Must Supporttrue
            Summaryfalse
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            44. DocumentReference.relatesTo
            Definition

            Relationships that this document has with other document references that already exist.

            ShortRelationships to other documents
            Comments

            This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

            Control0..*
            TypeBackboneElement
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            46. DocumentReference.relatesTo.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            48. DocumentReference.relatesTo.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            50. DocumentReference.relatesTo.modifierExtension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

            ShortExtensions that cannot be ignored even if unrecognized
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            Requirements

            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

            Alternate Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            52. DocumentReference.relatesTo.code
            Definition

            The type of relationship that this document has with anther document.

            Shortreplaces | transforms | signs | appends
            Comments

            If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

            Control1..1
            BindingThe codes SHALL be taken from DocumentRelationshipType
            (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1)

            The type of relationship between documents.

            Typecode
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            54. DocumentReference.relatesTo.target
            Definition

            The target document of this relationship.

            ShortTarget of the relationship
            Control1..1
            TypeReference(DocumentReference)
            Is Modifierfalse
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            56. DocumentReference.description
            Definition

            Human-readable description of the source document.

            ShortHuman-readable description
            Comments

            What the document is about, a terse summary of the document.

            Control0..1
            Typestring
            Is Modifierfalse
            Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
            Summarytrue
            Requirements

            Helps humans to assess whether the document is of interest.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            58. DocumentReference.securityLabel
            Definition

            A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.

            ShortDocument security-tags
            Comments

            The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

            In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

            Control0..*
            BindingUnless not suitable, these codes SHALL be taken from All Security Labels
            (extensible to http://hl7.org/fhir/ValueSet/security-labels)

            Security Labels from the Healthcare Privacy and Security Classification System.

            TypeCodeableConcept
            Is Modifierfalse
            Summarytrue
            Requirements

            Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            60. DocumentReference.content
            Definition

            The document and format referenced. There may be multiple content element repetitions, each with a different format.

            Short(USCDI) Document referenced
            Control1..*
            TypeBackboneElement
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            62. DocumentReference.content.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            64. DocumentReference.content.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            66. DocumentReference.content.modifierExtension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

            Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

            ShortExtensions that cannot be ignored even if unrecognized
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
            Summarytrue
            Requirements

            Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

            Alternate Namesextensions, user content, modifiers
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            68. DocumentReference.content.attachment
            Definition

            The document or URL of the document along with critical metadata to prove content has integrity.

            Short(USCDI) Where to access the document
            Control1..1
            TypeAttachment
            Is Modifierfalse
            Must Supporttrue
            Summarytrue
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. (url.exists() or data.exists())
            70. DocumentReference.content.attachment.id
            Definition

            Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

            ShortUnique id for inter-element referencing
            Control0..1
            Typestring
            Is Modifierfalse
            XML FormatIn the XML format, this property is represented as an attribute.
            Summaryfalse
            72. DocumentReference.content.attachment.extension
            Definition

            May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

            ShortAdditional content defined by implementations
            Comments

            There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

            Control0..*
            TypeExtension
            Is Modifierfalse
            Summaryfalse
            Alternate Namesextensions, user content
            Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
            ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
            SlicingThis element introduces a set of slices on DocumentReference.content.attachment.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators:
            • value @ url
            • 74. DocumentReference.content.attachment.contentType
              Definition

              Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.

              Short(USCDI) Mime type of the content, with charset etc.
              Control1..1
              BindingThe codes SHALL be taken from Mime Types
              (required to http://hl7.org/fhir/ValueSet/mimetypes|4.0.1)

              The mime type of an attachment. Any valid mime type is allowed.

              Typecode
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              Processors of the data need to be able to know how to interpret the data.

              Example<br/><b>General</b>:text/plain; charset=UTF-8, image/png
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              76. DocumentReference.content.attachment.language
              Definition

              The human language of the content. The value can be any valid value according to BCP 47.

              ShortHuman language of the content (BCP-47)
              Control0..1
              BindingThe codes SHOULD be taken from CommonLanguages
              (preferred to http://hl7.org/fhir/ValueSet/languages)

              A human language.

              Additional BindingsPurpose
              AllLanguagesMax Binding
              Typecode
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Requirements

              Users need to be able to choose between the languages in a set of attachments.

              Example<br/><b>General</b>:en-AU
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              78. DocumentReference.content.attachment.data
              Definition

              The actual data of the attachment - a sequence of bytes, base64 encoded.

              Short(USCDI) Data inline, base64ed
              Comments

              The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.

              Control0..1
              This element is affected by the following invariants: us-core-6
              Typebase64Binary
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summaryfalse
              Requirements

              The data needs to able to be transmitted inline.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              80. DocumentReference.content.attachment.url
              Definition

              A location where the data can be accessed.

              Short(USCDI) Uri where the data can be found
              Comments

              If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.

              Control0..1
              This element is affected by the following invariants: us-core-6
              Typeurl
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              The data needs to be transmitted by reference.

              Example<br/><b>General</b>:http://www.acme.com/logo-small.png
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              82. DocumentReference.content.attachment.size
              Definition

              The number of bytes of data that make up this attachment (before base64 encoding, if that is done).

              ShortNumber of bytes of content (if url provided)
              Comments

              The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.

              Control0..1
              TypeunsignedInt
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Requirements

              Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              84. DocumentReference.content.attachment.hash
              Definition

              The calculated hash of the data using SHA-1. Represented using base64.

              ShortHash of the data (sha-1, base64ed)
              Comments

              The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see Provenance.signature for mechanism to protect a resource with a digital signature.

              Control0..1
              Typebase64Binary
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Requirements

              Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              86. DocumentReference.content.attachment.title
              Definition

              A label or set of text to display in place of the data.

              ShortLabel to display in place of the data
              Control0..1
              Typestring
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Summarytrue
              Requirements

              Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.

              Example<br/><b>General</b>:Official Corporate Logo
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              88. DocumentReference.content.attachment.creation
              Definition

              The date that the attachment was first created.

              ShortDate attachment was first created
              Control1..1
              TypedateTime
              Is Modifierfalse
              Primitive ValueThis primitive element may be present, or absent, or replaced by an extension
              Must Supporttrue
              Summarytrue
              Requirements

              This is often tracked as an integrity issue for use of the attachment.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              90. DocumentReference.content.format
              Definition

              An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

              Short(USCDI) Format/content rules for the document
              Comments

              Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

              Control0..1
              BindingUnless not suitable, these codes SHALL be taken from DocumentReferenceFormatCodeSet
              (extensible to http://hl7.org/fhir/ValueSet/formatcodes)
              TypeCoding
              Is Modifierfalse
              Must Supporttrue
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              92. DocumentReference.context
              Definition

              The clinical context in which the document was prepared.

              Short(USCDI) Clinical context of document
              Comments

              These values are primarily added to help with searching for interesting/relevant documents.

              Control0..1
              TypeBackboneElement
              Is Modifierfalse
              Must Supporttrue
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              94. DocumentReference.context.id
              Definition

              Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

              ShortUnique id for inter-element referencing
              Control0..1
              Typestring
              Is Modifierfalse
              XML FormatIn the XML format, this property is represented as an attribute.
              Summaryfalse
              96. DocumentReference.context.extension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

              ShortAdditional content defined by implementations
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifierfalse
              Summaryfalse
              Alternate Namesextensions, user content
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              98. DocumentReference.context.modifierExtension
              Definition

              May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

              Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

              ShortExtensions that cannot be ignored even if unrecognized
              Comments

              There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

              Control0..*
              TypeExtension
              Is Modifiertrue because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
              Summarytrue
              Requirements

              Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

              Alternate Namesextensions, user content, modifiers
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              ext-1: Must have either extensions or value[x], not both (extension.exists() != value.exists())
              100. DocumentReference.context.encounter
              Definition

              Describes the clinical encounter or type of care that the document content is associated with.

              Short(USCDI) Context of the document content
              Control0..1
              TypeReference(US Core Encounter Profile)
              Is Modifierfalse
              Must Supporttrue
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              102. DocumentReference.context.event
              Definition

              This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

              ShortMain clinical acts documented
              Comments

              An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

              Control0..*
              BindingFor example codes, see v3 Code System ActCode
              (example to http://terminology.hl7.org/ValueSet/v3-ActCode)

              This list of codes represents the main clinical acts being documented.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              104. DocumentReference.context.period
              Definition

              The time period over which the service that is described by the document was provided.

              Short(USCDI) Time of service that is being documented
              Control0..1
              TypePeriod
              Is Modifierfalse
              Must Supporttrue
              Summarytrue
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              106. DocumentReference.context.facilityType
              Definition

              The kind of facility where the patient was seen.

              ShortKind of facility where patient was seen
              Control0..1
              BindingFor example codes, see FacilityTypeCodeValueSet
              (example to http://hl7.org/fhir/ValueSet/c80-facilitycodes)

              XDS Facility Type.

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              108. DocumentReference.context.practiceSetting
              Definition

              This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

              ShortAdditional details about where the content was created (e.g. clinical specialty)
              Comments

              This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

              Control0..1
              BindingFor example codes, see PracticeSettingCodeValueSet
              (example to http://hl7.org/fhir/ValueSet/c80-practice-codes)

              Additional details about where the content was created (e.g. clinical specialty).

              TypeCodeableConcept
              Is Modifierfalse
              Summaryfalse
              Requirements

              This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              110. DocumentReference.context.sourcePatientInfo
              Definition

              The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

              ShortPatient demographics from source
              Control0..1
              TypeReference(Patient)
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))
              112. DocumentReference.context.related
              Definition

              Related identifiers or resources associated with the DocumentReference.

              ShortRelated identifiers or resources
              Comments

              May be identifiers or resources that caused the DocumentReference or referenced Document to be created.

              Control0..*
              TypeReference(Resource)
              Is Modifierfalse
              Summaryfalse
              Invariantsele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))