Mobile access to Health Documents (MHD)
4.2.2 - Trial-Implementation
Mobile access to Health Documents (MHD)
4.2.2 - Trial-Implementation
Mobile access to Health Documents (MHD), published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 4.2.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/IHE/ITI.MHD/ and changes regularly. See the Directory of published versions
| Official URL: https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.SimplifiedPublish.DocumentReference | Version: 4.2.2 | |||
| Active as of 2024-05-17 | Computable Name: SimplifiedPublishDocumentReference | |||
A profile on the DocumentReference resource for MHD Simplified Publish constraints.
Simplified Publish
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference |
0..* | DocumentReference | A reference to a document | |
  modifierExtension |
0..0 | |||
 masterIdentifier |
1..1 | Identifier | Master Version Specific Identifier | |
| identifier |
0..0 | |||
| status |
1..1 | code | current | superseded | entered-in-error Required Pattern: current | |
| docStatus |
0..0 | |||
| type |
S | 0..1 | CodeableConcept | Kind of document (LOINC if possible) |
| category |
S | 0..1 | CodeableConcept | Categorization of document |
 subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |
| date |
S | 0..1 | instant | When this document reference was created |
| 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 |
1..1 | BackboneElement | Document referenced | |
 attachment |
||||
| contentType |
1..1 | code | Mime type of the content, with charset etc. | |
| language |
S | 0..1 | code | Human language of the content (BCP-47) |
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |
| url |
0..0 | |||
 creation |
S | 0..1 | dateTime | Date attachment was first created |
| format |
S | 0..1 | Coding | Format/content rules for the document |
| context |
||||
 period |
S | 0..1 | Period | Time of service that is being documented |
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen |
| practiceSetting |
S | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) |
| sourcePatientInfo |
S | 0..1 | Reference(Patient) | Patient demographics from source |
| 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 | ||||
 masterIdentifier |
Σ | 1..1 | Identifier | Master Version Specific Identifier | ||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | ||||
| relatesTo |
SΣ | 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 |
SΣ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
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 | ||||
| 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. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |||||
| creation |
SΣ | 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 |
Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
S | 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 |
S | 0..1 | Reference(Patient) | Patient demographics from source | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.status | required | Pattern: currenthttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| masterIdentifier |
Σ | 1..1 | Identifier | Master Version Specific Identifier | ||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 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 |
SΣ | 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 |
SΣ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
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 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
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. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 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 |
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 |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
S | 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 |
S | 0..1 | Reference(Patient) | Patient demographics from source | ||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | Pattern: currenthttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from DocumentReference
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| modifierExtension |
0..0 | |||
| masterIdentifier |
1..1 | Identifier | Master Version Specific Identifier | |
| identifier |
0..0 | |||
| status |
1..1 | code | current | superseded | entered-in-error Required Pattern: current | |
| docStatus |
0..0 | |||
| type |
S | 0..1 | CodeableConcept | Kind of document (LOINC if possible) |
| category |
S | 0..1 | CodeableConcept | Categorization of document |
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |
| date |
S | 0..1 | instant | When this document reference was created |
| 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 |
1..1 | BackboneElement | Document referenced | |
| attachment |
||||
| contentType |
1..1 | code | Mime type of the content, with charset etc. | |
| language |
S | 0..1 | code | Human language of the content (BCP-47) |
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |
| url |
0..0 | |||
| creation |
S | 0..1 | dateTime | Date attachment was first created |
| format |
S | 0..1 | Coding | Format/content rules for the document |
| context |
||||
| period |
S | 0..1 | Period | Time of service that is being documented |
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen |
| practiceSetting |
S | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) |
| sourcePatientInfo |
S | 0..1 | Reference(Patient) | Patient demographics from source |
| 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 | ||||
| masterIdentifier |
Σ | 1..1 | Identifier | Master Version Specific Identifier | ||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | ||||
| relatesTo |
SΣ | 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 |
SΣ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
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 | ||||
| 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. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |||||
| creation |
SΣ | 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 |
Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
S | 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 |
S | 0..1 | Reference(Patient) | Patient demographics from source | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.status | required | Pattern: currenthttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| masterIdentifier |
Σ | 1..1 | Identifier | Master Version Specific Identifier | ||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
| category |
SΣ | 0..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
Σ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 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 |
SΣ | 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 |
SΣ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
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 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
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. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| data |
1..1 | base64Binary | The document is contained in the .data element, base64 encoded | |||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 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 |
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 |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
S | 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 |
S | 0..1 | Reference(Patient) | Patient demographics from source | ||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | Pattern: currenthttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodesfrom the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from DocumentReference
Other representations of profile: CSV, Excel, Schematron
IG © 2020+ IHE IT Infrastructure Technical Committee. Package ihe.iti.mhd#4.2.2 based on FHIR 4.0.1. Generated 2024-05-17
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