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

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Resource Profile: MHR DocumentReference

The purpose of this profile is to provide a representation of a document reference for CDA documents in My Health Record. 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 is derived from the DocumentReference resource and describes the data structures and obligations to be met when conforming to this profile.

Usage:

• Refer to this Resource Profile: MHR Medical Conditions View Provenance
• Examples for this Resource Profile: DocumentReference/mcv-ds-01

Formal Views of Profile Content

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

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
masterIdentifier	SO	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SO	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	SO	1..1	code	current | superseded | entered-in-error Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SO	0..1	code	preliminary | final | amended | entered-in-error Obligations Actor SHALL:handle MHR Gateway Requester
type	SO	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SO	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SO	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SO	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SO	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
description	SO	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
content	SO	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
attachment	SO	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SO	0..1	Coding	Format/content rules for the document Obligations Actor SHALL:handle MHR Gateway Requester
context	SO	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
period	SO	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Obligations Actor SHALL:handle MHR Gateway Requester
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SOΣ	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SOΣ	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	?!SOΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SOΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. Obligations Actor SHALL:handle MHR Gateway Requester
type	SOΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SOΣ	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SOΣ	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SOΣ	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SOΣ	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
description	SOΣ	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
content	SOΣ	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SOΣ	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SOΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. Obligations Actor SHALL:handle MHR Gateway Requester
context	SOΣ	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
period	SOΣ	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	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). Obligations Actor SHALL:handle MHR Gateway Requester
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	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
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.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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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	SOΣ	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SOΣ	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	?!SOΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SOΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. Obligations Actor SHALL:handle MHR Gateway Requester
type	SOΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SOΣ	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SOΣ	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SOΣ	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SOΣ	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
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	SOΣ	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SOΣ	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
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	SOΣ	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SOΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. Obligations Actor SHALL:handle MHR Gateway Requester
context	SOΣ	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SOΣ	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	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). Obligations Actor SHALL:handle MHR Gateway Requester
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
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

This structure is derived from DocumentReference

Summary

Mandatory: 8 elements
Must-Support: 18 elements

Structures

This structure refers to these other structures:

• MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
• AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
• AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
masterIdentifier	SO	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SO	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	SO	1..1	code	current | superseded | entered-in-error Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SO	0..1	code	preliminary | final | amended | entered-in-error Obligations Actor SHALL:handle MHR Gateway Requester
type	SO	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SO	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SO	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SO	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SO	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
description	SO	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
content	SO	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
attachment	SO	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SO	0..1	Coding	Format/content rules for the document Obligations Actor SHALL:handle MHR Gateway Requester
context	SO	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
period	SO	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Obligations Actor SHALL:handle MHR Gateway Requester
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SOΣ	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SOΣ	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	?!SOΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SOΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. Obligations Actor SHALL:handle MHR Gateway Requester
type	SOΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SOΣ	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SOΣ	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SOΣ	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SOΣ	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
description	SOΣ	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
content	SOΣ	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SOΣ	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SOΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. Obligations Actor SHALL:handle MHR Gateway Requester
context	SOΣ	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
period	SOΣ	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	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). Obligations Actor SHALL:handle MHR Gateway Requester
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	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
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.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

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. 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	SOΣ	1..1	Identifier	Master Version Specific Identifier Obligations Actor SHALL:handle MHR Gateway Requester
identifier	SOΣ	1..1	Identifier	Other identifiers for the document Obligations Actor SHALL:handle MHR Gateway Requester
status	?!SOΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Obligations Actor SHALL:handle MHR Gateway Requester
docStatus	SOΣ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. Obligations Actor SHALL:handle MHR Gateway Requester
type	SOΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
category	SOΣ	1..*	CodeableConcept	Categorization of document Binding: My Health Record Record Class (extensible) Obligations Actor SHALL:handle MHR Gateway Requester
subject	SOΣ	1..1	Reference(MHR Patient)	Who/what is the subject of the document Obligations Actor SHALL:handle MHR Gateway Requester
date	SOΣ	1..1	instant	When this document reference was created Obligations Actor SHALL:handle MHR Gateway Requester
author	SOΣ	1..1	Reference(MHR Patient | AU Core Practitioner)	Who and/or what authored the document Obligations Actor SHALL:handle MHR Gateway Requester
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian	SO	1..1	Reference(AU Core Organization)	Organization which maintains the document Obligations Actor SHALL:handle MHR Gateway Requester
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	SOΣ	0..1	string	Human-readable description Obligations Actor SHALL:handle MHR Gateway Requester
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SOΣ	1..*	BackboneElement	Document referenced Obligations Actor SHALL:handle MHR Gateway Requester
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	SOΣ	1..1	Attachment	Where to access the document Obligations Actor SHALL:handle MHR Gateway Requester
format	SOΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. Obligations Actor SHALL:handle MHR Gateway Requester
context	SOΣ	0..1	BackboneElement	Clinical context of document Obligations Actor SHALL:handle MHR Gateway Requester
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SOΣ	0..1	Period	Time of service that is being documented Obligations Actor SHALL:handle MHR Gateway Requester
facilityType	SO	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. Obligations Actor SHALL:handle MHR Gateway Requester
practiceSetting	SO	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). Obligations Actor SHALL:handle MHR Gateway Requester
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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	extensible	MyHealthRecordRecordType https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1 from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category	extensible	MyHealthRecordRecordClass https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1 from https://tx.ontoserver.csiro.au/fhir
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

This structure is derived from DocumentReference

Summary

Mandatory: 8 elements
Must-Support: 18 elements

Structures

This structure refers to these other structures:

• MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
• AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
• AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)

Other representations of profile: CSV, Excel, Schematron