Polska specyfikacja bazowa HL7 FHIR (HL7 FHIR PL Base), published by HL7 Poland. This guide is not an authorized publication; it is the continuous build for version 0.1.2 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7-Poland/pl-fhir-base/ and changes regularly. See the Directory of published versions

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Resource Profile: DocumentReference: Metadane dokumentu medycznego HL7 CDA

Metadane dokumentu medycznego zgodnego z PIK HL7 CDA

Usages:

• This Profile is not used by any profiles in this Implementation Guide

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	Business identifiers for the document
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣC	1..1	string	The value that is unique Example General: 123456
version	SΣ	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document.
Slices for coding	SΣ	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
coding:p1DocumentType	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
context	C	0..*	Reference(Appointment | Encounter | EpisodeOfCare)	Context of the document content
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes|5.0.0 From the FHIR Standard
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	1..*	Identifier	Business identifiers for the document
system	S	1..1	uri	The namespace for the identifier value
value	S	1..1	string	The value that is unique
version	S	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
Slices for coding	S	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
code	S	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
coding:p1DocumentType	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
code	S	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	Business identifiers for the document
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣC	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
version	SΣ	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document.
modality	Σ	0..*	CodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
version	Σ	0..1	string	Version of the system - if relevant
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
display	ΣC	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
coding:p1DocumentType	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
version	Σ	0..1	string	Version of the system - if relevant
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
display	ΣC	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	0..1	Reference(Resource)	Who/what is the subject of the document
context	C	0..*	Reference(Appointment | Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	CodeableReference(BodyStructure)	Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
facilityType	C	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	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).
period	Σ	0..1	Period	Time of service that is being documented
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of the 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
mode		1..1	CodeableConcept	personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document.
time		0..1	dateTime	When the document was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the document
custodian		0..1	Reference(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	CodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	markdown	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
profile	Σ	0..*	BackboneElement	Content profile rules for the 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
value[x]	Σ	1..1		Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes.
valueCoding			Coding
valueUri			uri
valueCanonical			canonical(Any)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes|5.0.0 From the FHIR Standard
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category|5.0.0 From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site|5.0.0 From the FHIR Standard
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes|5.0.0 From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes|5.0.0 From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|5.0.0 From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|5.0.0 From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples|5.0.0 From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DocumentReference

Summary

Mandatory: 11 elements
Must-Support: 12 elements

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.type.coding

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	Business identifiers for the document
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	SΣ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣC	1..1	string	The value that is unique Example General: 123456
version	SΣ	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document.
Slices for coding	SΣ	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
coding:p1DocumentType	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
context	C	0..*	Reference(Appointment | Encounter | EpisodeOfCare)	Context of the document content
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes|5.0.0 From the FHIR Standard
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	1..*	Identifier	Business identifiers for the document
system	S	1..1	uri	The namespace for the identifier value
value	S	1..1	string	The value that is unique
version	S	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
Slices for coding	S	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
code	S	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
coding:p1DocumentType	S	1..1	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
code	S	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	1..*	Identifier	Business identifiers for the document
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	SΣ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	SΣC	1..1	string	The value that is unique Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
version	SΣ	1..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document.
modality	Σ	0..*	CodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document.
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	2..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
coding:loincDocumentType	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.com
version	Σ	0..1	string	Version of the system - if relevant
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: FHIRDocumentTypeCodes (required)
display	ΣC	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
coding:p1DocumentType	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://hl7.org.pl/fhir/CodeSystem/pl-p1DocumentType-CS
version	Σ	0..1	string	Version of the system - if relevant
code	SΣC	1..1	code	Symbol in syntax defined by the system Binding: Typ dokumentu medycznego wg P1 (PL) (required)
display	ΣC	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	0..1	Reference(Resource)	Who/what is the subject of the document
context	C	0..*	Reference(Appointment | Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	CodeableReference(BodyStructure)	Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
facilityType	C	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	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).
period	Σ	0..1	Period	Time of service that is being documented
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of the 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
mode		1..1	CodeableConcept	personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document.
time		0..1	dateTime	When the document was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the document
custodian		0..1	Reference(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	CodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	markdown	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
profile	Σ	0..*	BackboneElement	Content profile rules for the 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
value[x]	Σ	1..1		Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes.
valueCoding			Coding
valueUri			uri
valueCanonical			canonical(Any)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	preferred	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes|5.0.0 From the FHIR Standard
DocumentReference.type.coding:loincDocumentType.code	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.type.coding:p1DocumentType.code	required	PLP1DocumentTypeVS(a valid code from Typ dokumentu medycznego wg P1 (PL)) http://hl7.org.pl/fhir/ig/pl-base/ValueSet/pl-p1DocumentType-VS From this IG
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category|5.0.0 From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site|5.0.0 From the FHIR Standard
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes|5.0.0 From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes|5.0.0 From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode|5.0.0 From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|5.0.0 From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples|5.0.0 From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	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 : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from DocumentReference

Summary

Mandatory: 11 elements
Must-Support: 12 elements

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.type.coding

Other representations of profile: CSV, Excel, Schematron