HL7.FHIR.US.PACIO-ADI\PACIO ADI Document Reference

PACIO Advance Directive Interoperability Implementation Guide
0.1.0 - STU1

PACIO Advance Directive Interoperability Implementation Guide, published by HL7 Patient Empowerment Working Group. This is not an authorized publication; it is the continuous build for version 0.1.0). This version is based on the current content of https://github.com/HL7/pacio-adi/ and changes regularly. See the Directory of published versions

Resource Profile: PACIO ADI Document Reference

Defining URL:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-DocumentReference

Version:

0.1.0

Name:

PADIDocumentReference

Title:

PACIO ADI Document Reference

Status:

Active as of 2021-11-08T23:13:35+00:00

Definition:

This profile defines constraints that represent the information needed to register an advance directive information document on a FHIR server.

Publisher:

HL7 Patient Empowerment Working Group

Source Resource:

XML / JSON / Turtle

The official URL for this profile is:

http://hl7.org/fhir/us/pacio-adi/StructureDefinition/PADI-DocumentReference

Formal Views of Profile Content

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

This structure is derived from DocumentReference

Summary

Mandatory: 4 elements
Must-Support: 17 elements

Structures

This structure refers to these other structures:

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	Other identifiers for the document
status	S	1..1	code	current \| superseded \| entered-in-error
type	S	1..1	CodeableConcept	Advance Directive Categories Binding: Advance Directive Categories (extensible)
category	S	1..*	CodeableConcept	Categorization of document Binding: US Core DocumentReference Category (extensible)
subject	S	1..1	Reference(US Core Patient Profile)	Patient
date	S	0..1	instant	When this document reference was created
author	S	0..*	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)	legalAuthenticator
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
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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
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	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: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	Advance Directive Categories Binding: Advance Directive Categories (extensible)
category	SΣ	1..*	CodeableConcept	Categorization of document Binding: US Core DocumentReference Category (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)	legalAuthenticator
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
Slices for 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) Max Binding: AllLanguages: 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	Σ	0..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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current \| superseded \| entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	1..1	CodeableConcept	Advance Directive Categories Binding: Advance Directive Categories (extensible)
category	Σ	1..*	CodeableConcept	Categorization of document Binding: US Core DocumentReference Category (extensible)
subject	Σ	1..1	Reference(US Core Patient Profile)	Patient
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)	legalAuthenticator
custodian		0..1	Reference(US Core Organization Profile)	Organization which maintains the document
content	Σ	1..*	BackboneElement	Document referenced
attachment	Σ	1..1	Attachment	Where to access the document
contentType	Σ	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.
data		0..1	base64Binary	Data inline, base64ed
url	Σ	0..1	url	Uri where the data can be found
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..1	BackboneElement	Clinical context of document
encounter		0..*	Reference(US Core Encounter Profile)	Context of the document content
period	Σ	0..1	Period	Time of service that is being documented
Documentation for this format

This structure is derived from DocumentReference

Summary

Mandatory: 4 elements
Must-Support: 17 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	Other identifiers for the document
status	S	1..1	code	current \| superseded \| entered-in-error
type	S	1..1	CodeableConcept	Advance Directive Categories Binding: Advance Directive Categories (extensible)
category	S	1..*	CodeableConcept	Categorization of document Binding: US Core DocumentReference Category (extensible)
subject	S	1..1	Reference(US Core Patient Profile)	Patient
date	S	0..1	instant	When this document reference was created
author	S	0..*	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)	legalAuthenticator
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
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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	string	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) Max Binding: AllLanguages: A human language.
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	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: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	Advance Directive Categories Binding: Advance Directive Categories (extensible)
category	SΣ	1..*	CodeableConcept	Categorization of document Binding: US Core DocumentReference Category (extensible)
subject	SΣ	1..1	Reference(US Core Patient Profile)	Patient
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile \| US Core Organization Profile \| US Core Patient Profile)	legalAuthenticator
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
Slices for 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) Max Binding: AllLanguages: 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	Σ	0..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

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Max Binding: AllLanguages
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	extensible	PADIAdvanceDirectiveCategoriesVS
DocumentReference.category	extensible	USCoreDocumentReferenceCategory
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types
DocumentReference.content.attachment.language	preferred	CommonLanguages Max Binding: AllLanguages
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet