Australian Digital Health Agency FHIR
1.2.0-ci-build - draft
Australian Digital Health Agency FHIR
1.2.0-ci-build - draft
Australian Digital Health Agency FHIR, 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/mcv/ and changes regularly. See the Directory of published versions
| Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-documentreference-core-1 | Version: 1.0.0 | |||
| Active as of 2024-09-16 | 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/. |
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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:
None.
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 |
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S | 1..1 | code | current | superseded | entered-in-error |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 | ||||
| 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 |
 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 |
| 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 |
| 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 |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-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 |
| 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.
| |||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-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.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 |
| 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:
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 | ||||
| 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 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 |
| 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 |
| 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 |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-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 |
| 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.
| |||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-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.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 |
| 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:
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ Australian Digital Health Agency. Package au.digitalhealth.r4#1.2.0-ci-build based on FHIR 4.0.1. Generated 2024-09-16
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