PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2
PACIO Advance Directive Interoperability Implementation Guide
2.1.0 - STU 2
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
| Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-DocumentReference | Version: 2.1.0 | |||
| Active as of 2024-12-06 | Computable Name: ADIDocumentReference | |||
This profile defines constraints that represent the information needed to register an advance directive information document on a FHIR server.
Conformance:
Advance Directive Information versionNumber represents a string value used to version successive replacement documents. Best practice for systems that support distributed document creation and updating is to populate the versionNumber with the timestamp created from the date/time when the version of the document is created in the system. Note: this may or may not be equivalent to the timestamp integer for Composition.date. the versionNumber timestamp always will be equivalent to the Bundle.timestamp for the document.
To better align with CDA, versionNumber should be a string label generated by converting the ClinicalDocument.effectiveTime (or Composition.date) to UTC time (-0000) and then using the YYYYMMDDhhmmss as the version.
For documents created within a system will follow the pattern that the timestamp-label versionNumber will be equivalent to the timestamp of the Composition.date and the Bundle.timestamp. However, for unstructured historical documents uploaded into a system, the timestamp-label versionNumber will be equivalent to the timestamp of the timestamp of the system dateTime when the document was uploaded, but the Composition.date will reflect the creation date of the original document, if it is available. If the creation date of the original document is not known, then Composition.date may be the system dateTime when the document is uploaded.
This profile defines constraints that represent the information needed to register an advance directive information document on a FHIR server. Temporal information is essential to the document registration process. DocumentReference.date holds the date when the document was registered and DocumentReference.content.attachment.creation holds the "creation date" associated with the document itself.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference |
0..* | DocumentReference | A reference to a document | |
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
   DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) |
 DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension |
  identifier |
S | 0..* | Identifier | Other identifiers for the document |
| status |
S | 1..1 | code | current | superseded | entered-in-error |
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) | |
| type |
S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) |
| category |
S | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) |
 subject |
S | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
| date |
S | 1..1 | instant | When this document reference was created |
| author |
S | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document |
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
| content |
S | 1..* | BackboneElement | Document referenced |
| attachment |
S | 1..1 | Attachment | Where to access the document |
| contentType |
S | 1..1 | code | Mime type of the content, with charset etc. |
| data |
S | 0..1 | base64Binary | Data inline, base64ed |
| url |
S | 0..1 | url | Uri where the data can be found |
 creation |
S | 1..1 | dateTime | Date attachment was first created |
| format |
S | 0..1 | Coding | Format/content rules for the document |
 context |
S | 0..1 | BackboneElement | Clinical context of document |
 encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content |
| period |
S | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | |
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) |
| DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
 identifier |
SΣ | 0..* | Identifier | Other identifiers for the document |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) |
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. |
| category |
SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
| date |
SΣ | 1..1 | instant | When this document reference was created |
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document |
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| contentType |
SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png |
| data |
S | 0..1 | base64Binary | Data inline, base64ed |
| url |
SΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created |
| format |
SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. |
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content |
| period |
SΣ | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | |
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | |
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | |
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | |
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) | ||||
| DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 1..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document | ||||
| relatesTo |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
S | 0..1 | base64Binary | Data inline, base64ed | ||||
| url |
SΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content | ||||
| event |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from DocumentReference
Summary
Mandatory: 6 elements
Must-Support: 20 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) |
| DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension |
| identifier |
S | 0..* | Identifier | Other identifiers for the document |
| status |
S | 1..1 | code | current | superseded | entered-in-error |
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) | |
| type |
S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) |
| category |
S | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) |
| subject |
S | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
| date |
S | 1..1 | instant | When this document reference was created |
| author |
S | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document |
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
| content |
S | 1..* | BackboneElement | Document referenced |
| attachment |
S | 1..1 | Attachment | Where to access the document |
| contentType |
S | 1..1 | code | Mime type of the content, with charset etc. |
| data |
S | 0..1 | base64Binary | Data inline, base64ed |
| url |
S | 0..1 | url | Uri where the data can be found |
| creation |
S | 1..1 | dateTime | Date attachment was first created |
| format |
S | 0..1 | Coding | Format/content rules for the document |
| context |
S | 0..1 | BackboneElement | Clinical context of document |
| encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content |
| period |
S | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | |
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) |
| DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) |
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. |
| category |
SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) |
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document |
| date |
SΣ | 1..1 | instant | When this document reference was created |
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document |
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| contentType |
SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png |
| data |
S | 0..1 | base64Binary | Data inline, base64ed |
| url |
SΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created |
| format |
SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. |
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content |
| period |
SΣ | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | |
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | |
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | |
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | |
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| DocumentRevokeStatus |
S | 0..1 | code | Revoke Status URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-document-revoke-status Binding: ADI Document Revoke Status (required) | ||||
| DocumentReferenceVersionNumber |
S | 0..1 | string | Version Number URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/adi-docVersionNumber-extension | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: ADI Document Reference Status (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 1..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document | ||||
| relatesTo |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
S | 0..1 | base64Binary | Data inline, base64ed | ||||
| url |
SΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
S | 0..* | Reference(US Core Encounter Profile) | Context of the document content | ||||
| event |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | ADIDocumentReferenceStatusVShttp://hl7.org/fhir/us/pacio-adi/ValueSet/ADIDocumentReferenceStatusVSfrom this IG | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | extensible | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from DocumentReference
Summary
Mandatory: 6 elements
Must-Support: 20 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron
IG © 2021+ HL7 International / Patient Empowerment. Package hl7.fhir.us.pacio-adi#2.1.0 based on FHIR 4.0.1. Generated 2024-12-06
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