IHE SDC/electronic Cancer Protocols (eCPs) on FHIR
1.0.0 - trial-use

IHE SDC/electronic Cancer Protocols (eCPs) on FHIR, published by HL7 International - Orders and Observations. This is not an authorized publication; it is the continuous build for version 1.0.0). This version is based on the current content of https://github.com/HL7/ihe-sdc-ecc-on-fhir/ and changes regularly. See the Directory of published versions

## Resource Profile: DocumentReferenceSDCeCC - Detailed Descriptions

Active as of 2023-08-16

Definitions for the ihe-sdc-ecc-DocumentReference resource profile.

- Differential Elements Table
- Key Elements Table
- Snapshot Elements Table

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

1. DocumentReference
2. DocumentReference.masterIdentifier
Definition | the form's SDC ID should be replaced by form's instanceVersionGUID if the form has been filled 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.
Control | 10..1
Must Support | true
3. DocumentReference.identifier
Definition | Additional identifying information about the form such as its fullURI Other identifiers associated with the document, including version independent identifiers.
Note | This is a business identifier, not a resource identifier (see discussion)
Must Support | true
4. DocumentReference.category
Control | 10..*
Must Support | true
5. DocumentReference.subject
Must Support | true
6. DocumentReference.author
Must Support | true
7. DocumentReference.relatesTo
Must Support | true
8. DocumentReference.securityLabel
Must Support | true
9. DocumentReference.content
Control | 1..1*
Must Support | true
10. DocumentReference.context
Must Support | true

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

1. 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.
Control | 0..*
Summary | false
Comments | Usually, this is used for documents other than those defined by FHIR.
Invariants | Defined on this element dom-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.
Control | 0..1
Type | uri
Is Modifier | true
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
3. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | false
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 Names | extensions, user content
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.
Invariants | Defined on this element ele-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())
4. DocumentReference.masterIdentifier
Definition | the form's SDC ID should be replaced by form's instanceVersionGUID if the form has been filled 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.
Control | 10..1
Type | Identifier
Must Support | true
Summary | true
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.).
Comments | CDA Document Id extension and root.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. DocumentReference.identifier
Definition | Additional identifying information about the form such as its fullURI Other identifiers associated with the document, including version independent identifiers.
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Must Support | true
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. DocumentReference.status
Definition | The status of this document reference.
Control | 1..1
Binding | The codes SHALL be taken from DocumentReferenceStatus The status of the document reference.
Type | code
Is Modifier | true
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. 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.
Control | 10..*
Binding | For example codes, see DocumentClassValueSet High-level kind of a clinical document at a macro level.
Type | CodeableConcept
Must Support | true
Summary | true
Alternate Names | claxs
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
8. 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).
Control | 0..1
Type | Reference(Patient|Practitioner|Group|Device)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
9. DocumentReference.author
Definition | Identifies who is responsible for adding the information to the document.
Control | 0..*
Type | Reference(Practitioner|PractitionerRole|Organization|Device|Patient|RelatedPerson)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Comments | Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
10. DocumentReference.relatesTo
Definition | Relationships that this document has with other document references that already exist.
Control | 0..*
Type | BackboneElement
Must Support | true
Summary | true
Comments | This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())
12. DocumentReference.relatesTo.code
Definition | The type of relationship that this document has with anther document.
Control | 1..1
Binding | The codes SHALL be taken from DocumentRelationshipType The type of relationship between documents.
Type | code
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. DocumentReference.relatesTo.target
Definition | The target document of this relationship.
Control | 1..1
Type | Reference(DocumentReference)
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. 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.
Control | 0..*
Binding | The codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable Security Labels from the Healthcare Privacy and Security Classification System.
Type | CodeableConcept
Must Support | true
Summary | true
Requirements | Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. DocumentReference.content
Definition | The document and format referenced. There may be multiple content element repetitions, each with a different format.
Control | 1..1*
Type | BackboneElement
Must Support | true
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())
17. DocumentReference.content.attachment
Definition | The document or URL of the document along with critical metadata to prove content has integrity.
Control | 1..1
Type | Attachment
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. DocumentReference.context
Definition | The clinical context in which the document was prepared.
Control | 0..1
Type | BackboneElement
Must Support | true
Summary | true
Comments | These values are primarily added to help with searching for interesting/relevant documents.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())

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

1. 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.
Control | 0..*
Summary | false
Comments | Usually, this is used for documents other than those defined by FHIR.
2. DocumentReference.id
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
Control | 0..1
Type | id
Summary | true
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.
3. 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.
Control | 0..1
Type | Meta
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
4. 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.
Control | 0..1
Type | uri
Is Modifier | true
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
5. DocumentReference.language
Definition | The base language in which the resource is written.
Control | 0..1
Binding | The codes SHOULD be taken from CommonLanguages A human language
Additional Bindings | Purpose
AllLanguages | Max Binding
Type | code
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | false
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).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
6. 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.
Control | 0..1
Type | Narrative
Summary | false
Alternate Names | narrative, html, xhtml, display
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
7. 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.
Control | 0..*
Type | Resource
Summary | false
Alternate Names | inline resources, anonymous resources, contained 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.
8. DocumentReference.extension
Definition | 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.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, user content
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.
Invariants | Defined on this element ele-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())
9. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | false
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 Names | extensions, user content
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.
Invariants | Defined on this element ele-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.masterIdentifier
Definition | the form's SDC ID should be replaced by form's instanceVersionGUID if the form has been filled
Control | 1..1
Type | Identifier
Must Support | true
Summary | true
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.).
Comments | CDA Document Id extension and root.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
11. DocumentReference.identifier
Definition | Additional identifying information about the form such as its fullURI
Note | This is a business identifier, not a resource identifier (see discussion)
Control | 0..*
Type | Identifier
Must Support | true
Summary | true
Invariants | Defined on this element ele-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.
Control | 1..1
Binding | The codes SHALL be taken from DocumentReferenceStatus The status of the document reference
Type | code
Is Modifier | true
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
13. DocumentReference.docStatus
Definition | The status of the underlying document.
Control | 0..1
Binding | The codes SHALL be taken from CompositionStatus Status of the underlying document
Type | code
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Comments | The document that is pointed to might be in various lifecycle states.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
14. 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.
Control | 0..1
Binding | The codes SHOULD be taken from DocumentTypeValueSet Precise type of clinical document
Type | CodeableConcept
Summary | true
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
15. 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.
Control | 1..*
Binding | For example codes, see DocumentClassValueSet High-level kind of a clinical document at a macro level
Type | CodeableConcept
Must Support | true
Summary | true
Alternate Names | claxs
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
16. 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).
Control | 0..1
Type | Reference(Patient|Practitioner|Group|Device)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
17. DocumentReference.date
Definition | When the document reference was created.
Control | 0..1
Type | instant
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Alternate Names | indexed
Comments | Referencing/indexing time is used for tracking, organizing versions and searching.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
18. DocumentReference.author
Definition | Identifies who is responsible for adding the information to the document.
Control | 0..*
Type | Reference(Practitioner|PractitionerRole|Organization|Device|Patient|RelatedPerson)
Must Support | true
Must Support Types | No must-support rules about the choice of types/profiles
Summary | true
Comments | Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
19. DocumentReference.authenticator
Definition | Which person or organization authenticates that this document is valid.
Control | 0..1
Type | Reference(Practitioner|PractitionerRole|Organization)
Summary | false
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
20. DocumentReference.custodian
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.
Control | 0..1
Type | Reference(Organization)
Summary | false
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
21. DocumentReference.relatesTo
Definition | Relationships that this document has with other document references that already exist.
Control | 0..*
Type | BackboneElement
Must Support | true
Summary | true
Comments | This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
22. 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.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
Summary | false
23. 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.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, user content
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.
Invariants | Defined on this element ele-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())
24. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())
25. DocumentReference.relatesTo.code
Definition | The type of relationship that this document has with anther document.
Control | 1..1
Binding | The codes SHALL be taken from DocumentRelationshipType The type of relationship between documents
Type | code
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
26. DocumentReference.relatesTo.target
Definition | The target document of this relationship.
Control | 1..1
Type | Reference(DocumentReference)
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
27. DocumentReference.description
Definition | Human-readable description of the source document.
Control | 0..1
Type | string
Primitive Value | This primitive element may be present, or absent, or replaced by an extension
Summary | true
Requirements | Helps humans to assess whether the document is of interest.
Comments | What the document is about, a terse summary of the document.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
28. 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.
Control | 0..*
Binding | The codes SHALL be taken from All Security Labels; other codes may be used where these codes are not suitable Security Labels from the Healthcare Privacy and Security Classification System
Type | CodeableConcept
Must Support | true
Summary | true
Requirements | Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
29. DocumentReference.content
Definition | The document and format referenced. There may be multiple content element repetitions, each with a different format.
Control | 1..1
Type | BackboneElement
Must Support | true
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
30. 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.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
Summary | false
31. 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.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, user content
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.
Invariants | Defined on this element ele-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())
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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())
33. DocumentReference.content.attachment
Definition | The document or URL of the document along with critical metadata to prove content has integrity.
Control | 1..1
Type | Attachment
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
34. 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.
Control | 0..1
Binding | The codes SHOULD be taken from DocumentReferenceFormatCodeSet Document Format Codes
Type | Coding
Summary | true
Comments | Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
35. DocumentReference.context
Definition | The clinical context in which the document was prepared.
Control | 0..1
Type | BackboneElement
Must Support | true
Summary | true
Comments | These values are primarily added to help with searching for interesting/relevant documents.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
36. 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.
Control | 0..1
Type | string
XML Representation | In the XML format, this property is represented as an attribute.
Summary | false
37. 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.
Control | 0..*
Type | Extension
Summary | false
Alternate Names | extensions, user content
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.
Invariants | Defined on this element ele-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())
38. 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).
Control | 0..*
Type | Extension
Is Modifier | true
Summary | true
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 Names | extensions, user content, modifiers
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.
Invariants | Defined on this element ele-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())
39. DocumentReference.context.encounter
Definition | Describes the clinical encounter or type of care that the document content is associated with.
Control | 0..*
Type | Reference(Encounter|EpisodeOfCare)
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
40. 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.
Control | 0..*
Binding | For example codes, see v3 Code System ActCode This list of codes represents the main clinical acts being documented
Type | CodeableConcept
Summary | false
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
41. DocumentReference.context.period
Definition | The time period over which the service that is described by the document was provided.
Control | 0..1
Type | Period
Summary | true
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
42. DocumentReference.context.facilityType
Definition | The kind of facility where the patient was seen.
Control | 0..1
Binding | For example codes, see FacilityTypeCodeValueSet XDS Facility Type
Type | CodeableConcept
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
43. DocumentReference.context.practiceSetting
Definition | This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.
Control | 0..1
Binding | For example codes, see PracticeSettingCodeValueSet Additional details about where the content was created (e.g. clinical specialty)
Type | CodeableConcept
Summary | false
Requirements | This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.
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.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
44. DocumentReference.context.sourcePatientInfo
Definition | The Patient Information as known when the document was published. May be a reference to a version specific, or contained.
Control | 0..1
Type | Reference(Patient)
Summary | false
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))
45. DocumentReference.context.related
Definition | Related identifiers or resources associated with the DocumentReference.
Control | 0..*
Type | Reference(Resource)
Summary | false
Comments | May be identifiers or resources that caused the DocumentReference or referenced Document to be created.
Invariants | Defined on this element ele-1: All FHIR elements must have a @value or children (: hasValue() or (children().count() > id.count()))