Australian Digital Health Agency FHIR Implementation Guide

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:

• ADHA Advance Care Planning Document DocumentReference.
• ADHA Diagnostic Report DocumentReference.

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
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status	S	1..1	code	current | superseded | entered-in-error
docStatus	S	0..1	code	preliminary | final | amended | 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
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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())

Name	Flags	Card.	Type	Description & Constraints
DocumentReference	C	0..*	DocumentReference	A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
masterIdentifier	SΣ	0..1	Identifier	Master Version Specific Identifier ele-1: All FHIR elements must have a @value or children
identifier	SΣ	1..*	Identifier	Other identifiers for the document ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children
docStatus	SΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
category	SΣ	1..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
custodian	SC	0..1	Reference(ADHA Core Organization)	Organization which maintains the document ele-1: All FHIR elements must have a @value or children
description	SΣ	0..1	string	Human-readable description ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
context	SΣ	0..1	BackboneElement	Clinical context of document ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter	S	0..*	Reference(ADHA Core Encounter)	Context of the document content ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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())

Name	Flags	Card.	Type	Description & Constraints
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
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	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from 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/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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

Name	Flags	Card.	Type	Description & Constraints
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
docStatus	S	0..1	code	preliminary | final | amended | 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
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference	C	0..*	DocumentReference	A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management 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 ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
masterIdentifier	SΣ	0..1	Identifier	Master Version Specific Identifier ele-1: All FHIR elements must have a @value or children
identifier	SΣ	1..*	Identifier	Other identifiers for the document ele-1: All FHIR elements must have a @value or children
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children
docStatus	SΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. ele-1: All FHIR elements must have a @value or children
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
category	SΣ	1..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
subject	SΣC	1..1	Reference(ADHA Core Patient)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
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 ele-1: All FHIR elements must have a @value or children 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 ele-1: All FHIR elements must have a @value or children
custodian	SC	0..1	Reference(ADHA Core Organization)	Organization which maintains the document ele-1: All FHIR elements must have a @value or children
description	SΣ	0..1	string	Human-readable description ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
context	SΣ	0..1	BackboneElement	Clinical context of document ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter	S	0..*	Reference(ADHA Core Encounter)	Context of the document content ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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

Name	Flags	Card.	Type	Description & Constraints
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
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	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
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from 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/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
inv-dh-docref-01	error	DocumentReference.subject	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-02	error	DocumentReference.author	At least reference or a valid identifier shall be present : reference.exists() or identifier.where(system.count() + value.count() >1).exists()
inv-dh-docref-03	error	DocumentReference	If 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())

This structure is derived from DocumentReference

Summary

Mandatory: 6 elements
Must-Support: 16 elements

Structures

This structure refers to these other structures:

• ADHA Core Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-core-1)
• ADHA Authoring PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-author-1)
• ADHA Core Organization (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-organization-core-1)
• ADHA System Device (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-device-system-1)
• ADHA Authoring RelatedPerson (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-relatedperson-author-1)
• ADHA Core PractitionerRole (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-practitionerrole-core-1)
• ADHA Core Encounter (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-encounter-core-1)

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.

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)