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: IHE SDC/eCP on FHIR DocumentReference

Official URL: http://hl7.org/fhir/uv/ihe-sdc-ecc/StructureDefinition/ihe-sdc-ecc-DocumentReference | Version: 1.0.0
Active as of 2023-08-16 | Computable Name: DocumentReferenceSDCeCC

A DocumentReference Profile meant to share an IHE SDC Form whether completed or blank

Usage:

- Examples for this Resource Profile: DocumentReference/eCCDocRef0

### Formal Views of Profile Content

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

- Differential Table
- Key Elements Table
- Snapshot Table
- Statistics/References
- All

This structure is derived from DocumentReference

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
masterIdentifier | S | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S | 0..* | Identifier | form identifying information
category | S | 1..* | CodeableConcept | Categorization of document
subject | S | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
author | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
relatesTo | S | 0..* | BackboneElement | Relationships to other documents
securityLabel | S | 0..* | CodeableConcept | Document security-tags
content | S | 1..1 | BackboneElement | Document referenced
context | S | 0..1 | BackboneElement | Clinical context of document
Documentation for this format

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
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S Σ | 0..* | Identifier | form identifying information
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
author | S Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
relatesTo | S Σ | 0..* | BackboneElement | Relationships to other documents
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
securityLabel | S Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..1 | BackboneElement | Document referenced
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | Σ | 1..1 | Attachment | Where to access the document
context | S Σ | 0..1 | BackboneElement | Clinical context of document
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet
DocumentReference.status | required | DocumentReferenceStatus
DocumentReference.category | example | DocumentClassValueSet
DocumentReference.relatesTo.code | required | DocumentRelationshipType
DocumentReference.securityLabel | extensible | All Security Labels

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S Σ | 0..* | Identifier | form identifying information
status | ?!Σ | 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: CompositionStatus (required): Status of the underlying document.
type | Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
date | Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
relatesTo | S 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 | S Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..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 | Σ | 1..1 | Attachment | Where to access the document
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context | S Σ | 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 |  | 0..* | Reference(Encounter | EpisodeOfCare) | 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 | Σ | 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

#### Terminology Bindings

Path | Conformance | ValueSet
DocumentReference.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus
DocumentReference.docStatus | required | CompositionStatus
DocumentReference.type | preferred | DocumentTypeValueSet
DocumentReference.category | example | DocumentClassValueSet
DocumentReference.relatesTo.code | required | DocumentRelationshipType
DocumentReference.securityLabel | extensible | All Security Labels
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`)
DocumentReference.context.event | example | ActCode
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet

#### Constraints

Id | Grade | Path(s) | Details | Requirements
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from DocumentReference

Summary

Mandatory: 2 elements
Must-Support: 9 elements

Differential View

This structure is derived from DocumentReference

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
masterIdentifier | S | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S | 0..* | Identifier | form identifying information
category | S | 1..* | CodeableConcept | Categorization of document
subject | S | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
author | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
relatesTo | S | 0..* | BackboneElement | Relationships to other documents
securityLabel | S | 0..* | CodeableConcept | Document security-tags
content | S | 1..1 | BackboneElement | Document referenced
context | S | 0..1 | BackboneElement | Clinical context of document
Documentation for this format

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
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S Σ | 0..* | Identifier | form identifying information
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
author | S Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
relatesTo | S Σ | 0..* | BackboneElement | Relationships to other documents
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
securityLabel | S Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..1 | BackboneElement | Document referenced
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | Σ | 1..1 | Attachment | Where to access the document
context | S Σ | 0..1 | BackboneElement | Clinical context of document
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet
DocumentReference.status | required | DocumentReferenceStatus
DocumentReference.category | example | DocumentClassValueSet
DocumentReference.relatesTo.code | required | DocumentRelationshipType
DocumentReference.securityLabel | extensible | All Security Labels

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() |
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() |
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

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.
Additional Bindings | Purpose
AllLanguages | Max Binding
text |  | 0..1 | Narrative | Text summary of the resource, for human interpretation
contained |  | 0..* | Resource | Contained, inline Resources
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored
masterIdentifier | S Σ | 1..1 | Identifier | the form's SDC ID if blank, or @instanceVersionGUID if filled
identifier | S Σ | 0..* | Identifier | form identifying information
status | ?!Σ | 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: CompositionStatus (required): Status of the underlying document.
type | Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document
date | Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
relatesTo | S 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 | S Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..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 | Σ | 1..1 | Attachment | Where to access the document
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context | S Σ | 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 |  | 0..* | Reference(Encounter | EpisodeOfCare) | 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 | Σ | 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

#### Terminology Bindings

Path | Conformance | ValueSet
DocumentReference.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus
DocumentReference.docStatus | required | CompositionStatus
DocumentReference.type | preferred | DocumentTypeValueSet
DocumentReference.category | example | DocumentClassValueSet
DocumentReference.relatesTo.code | required | DocumentRelationshipType
DocumentReference.securityLabel | extensible | All Security Labels
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`)
DocumentReference.context.event | example | ActCode
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet

#### Constraints

Id | Grade | Path(s) | Details | Requirements
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |

This structure is derived from DocumentReference

Summary

Mandatory: 2 elements
Must-Support: 9 elements

Other representations of profile: CSV, Excel, Schematron