Australian Digital Health Agency FHIR Implementation Guide
1.2.0-ci-build - draft Australia flag

Australian Digital Health Agency FHIR Implementation Guide, published by Australian Digital Health Agency. This guide is not an authorized publication; it is the continuous build for version 1.2.0-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/AuDigitalHealth/ci-fhir-r4/ and changes regularly. See the Directory of published versions

Resource Profile: ADHA Core DocumentReference

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-documentreference-core-1 Version: 1.0.0
Active as of 2024-09-12 Computable Name: ADHADocumentReferenceCore

Copyright/Legal: Copyright © 2022 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to provide a core representation of a document reference for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile supports describing a document that is made available to a system and is used for documents that are not authored and assembled in FHIR e.g. documents whose form is an attachment.

This profile identifies the additional constraints, extensions, and value sets that build on and extend DocumentReference that are supported.

Where a more specific DocumentReference profile is applicable, e.g. advance care plan , an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set a core DocumentReference standard for:

  • Query for a generic document reference for a patient
  • Record or update a generic document reference belonging to a patient

This profile may be referred to by APIs, which will be listed here when available.

Profile specific guidance

None.

Boundaries and relationships

These profiles build on this profile (ADHA Core DocumentReference) to define specific document compositions:

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... masterIdentifier S 0..1 Identifier Master Version Specific Identifier
... identifier S 1..* Identifier Other identifiers for the document
... status S 1..1 code current | superseded | entered-in-error
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
... category S 1..* CodeableConcept Categorization of document
... subject SC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date S 1..1 instant When this document reference was created
... author SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) Organization which maintains the document
... description S 0..1 string Human-readable description
... content S 1..* BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
... context S 0..1 BackboneElement Clinical context of document
.... encounter S 0..* Reference(ADHA Core Encounter) Context of the document content

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 1..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ 1..1 instant When this document reference was created
... author SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) Organization which maintains the document
... description SΣ 0..1 string Human-readable description
... content SΣ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Where to access the document
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(ADHA Core Encounter) Context of the document content

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... 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
... 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 SΣ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 1..* 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 SΣ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 1..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ 1..1 instant When this document reference was created
... author SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) 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 SΣ 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
.... format Σ 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(ADHA Core Encounter) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... masterIdentifier S 0..1 Identifier Master Version Specific Identifier
... identifier S 1..* Identifier Other identifiers for the document
... status S 1..1 code current | superseded | entered-in-error
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
... category S 1..* CodeableConcept Categorization of document
... subject SC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date S 1..1 instant When this document reference was created
... author SC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) Organization which maintains the document
... description S 0..1 string Human-readable description
... content S 1..* BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
... context S 0..1 BackboneElement Clinical context of document
.... encounter S 0..* Reference(ADHA Core Encounter) Context of the document content

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 0..1 Identifier Master Version Specific Identifier
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 1..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ 1..1 instant When this document reference was created
... author SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) Organization which maintains the document
... description SΣ 0..1 string Human-readable description
... content SΣ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Where to access the document
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(ADHA Core Encounter) Context of the document content

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* DocumentReference A reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... 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
... 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 SΣ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 1..* 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 SΣ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ 1..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC 1..1 Reference(ADHA Core Patient) Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ 1..1 instant When this document reference was created
... author SΣC 1..* Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson) Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S 0..1 Reference(ADHA Core PractitionerRole | ADHA Core Organization) Who/what authenticated the document
... custodian SC 0..1 Reference(ADHA Core Organization) 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 SΣ 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
.... format Σ 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(ADHA Core Encounter) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
inv-dh-docref-01errorDocumentReference.subjectAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02errorDocumentReference.authorAt least reference or a valid identifier shall be present
: reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03errorDocumentReferenceIf present, a custodian shall at least have a reference or a valid identifier
: custodian.exists() implies custodian.all($this.reference.exists() or $this.display.exists() or $this.identifier.where(system.count() + value.count() >1).exists())

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
identifier token SHALL Master Version Specific Identifier DocumentReference.identifier | DocumentReference.masterIdentifier
category token SHALL Categorization of document DocumentReference.category
subject:identifier token SHALL Who/what is the subject of the document DocumentReference.subject.identifier
type token SHALL Kind of composition (LOINC if possible) DocumentReference.code
date date SHALL When this document reference was created DocumentReference.date
status token SHALL current | superseded | entered-in-error DocumentReference.status

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support searching for all document references for a patient using the subject:identifier search parameter:

    GET [base]/DocumentReference?subject:identifier={system|}[code]

    Example:

     GET [base]/DocumentReference?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437
    

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient (how to search by :identifier)

  2. SHALL support searching using the identifier search parameter:

    GET [base]/DocumentReference?identifier={system|}[code]

    Example:

     GET [base]/DocumentReference?identifier=urn:ietf:rfc:3986|urn:uuid:b487469d-810c-40ae-b5a9-c0beb9001c9f
    

    Implementation Notes: Fetches a bundle containing any DocumentReference resources matching the identifier (how to search by token)

  3. SHALL support searching using the combination subject:identifier and category and status search parameter:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DocumentReference?subject:identifier={system|}[code]&category[code]&status={system|}[code]

    Example:

     GET [base]/DocumentReference?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&category=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.16975&status=current
    

    Implementation Notes: Fetches a bundle of all DocumentReference resources with the category of "Advance Care Information" for the specified patient (how to search by :identifier and how to search by token)

  4. SHALL support searching using the combination subject:identifier and type and status search parameter:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DocumentReference?subject:identifier={system|}[code]&type={system|}[code]&status={system|}[code]

    Example:

     GET [base]/DocumentReference?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&type=https://healthterminologies.gov.au/fhir/CodeSystem/nctis-data-components-1|100.32016&status=current
    

    Implementation Notes: Fetches a bundle of all DocumentReference resources with the type of an 100.32016 (Goals of Care) for the specified patient (how to search by :identifier and how to search by token)

  5. SHALL support searching using the combination of the subject:identifier and date and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DocumentReference?subject:identifier={system|}[code]&date=[date]&status={system|}[code]&status={system|}[code]

    Example:

     GET [base]/DocumentReference?subject:identifier=http://ns.electronichealth.net.au/id/hi/ihi/1.0|8003608000228437&date=ge2013-03-14&status=current
    

    Implementation Notes: Fetches a bundle of all current DocumentReference resources for the specified patient that have a date greater than or equal to 21st Jan 2013. (how to search by :identifier and how to search by date)