US Core Implementation Guide
​9.0.0-ballot - United States of America flag

US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 9.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core ADI DocumentReference Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-adi-documentreference Version: 9.0.0-ballot
Standards status: Trial-use Active as of 2023-10-17 Maturity Level: 2 Computable Name: USCoreADIDocumentReferenceProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.4

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core Advance Directive Information (ADI) DocumentReference Profile inherits from the FHIR DocumentReference resource; refer to it for scope and usage definitions. It sets minimum expectations for searching and fetching patient Advance Directive Information (ADI) documents using the DocumentReference resource. Examples of advance healthcare directive documents include physician order for life sustaining treatment (POLST), do not resuscitate order (DNR), and medical power of attorney. In addition to the document contents, it communicates the type of advance directive document, the author, the verifier, and other properties. To represent whether advance directive documents exist for a patient, see the US Core Observation ADI Documentation Profile. To represent whether advance directive documents exist for a patient, see the US Core Observation ADI Documentation Profile. To represent orders based on an individual's Portable Medical Order (PMO), see the US Core PMO ServiceRequest Profile. This profile sets minimum expectations for searching and fetching patient ADI documents using the DocumentReference resource. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption.

Example Usage Scenarios:

The following are example usage scenarios for the US Core ADI DocumentReference profile:

  • Query for all ADI documents belonging to a Patient
  • Query for a specific ADI Document type (e.g., POLST or Living Will)

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each DocumentReference Must Have:

  1. a status
  2. a code describing the type of ADI document (for example, Advance Directive for intubation)
  3. an ADI document category (for example, Advance Directives)
  4. a patient
  5. document referenced (content)
  6. the MIME type (i.e., contentType) of the document

Each DocumentReference Must Support:

  1. a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
  2. date and time the DocumentReference was created
  3. an author*
  4. a verifier (in other words, an authenticator)
  5. a verification date
  6. a code identifying the specific details about the format of the document — over and above the content's MIME type

*see guidance below

Profile Specific Implementation Guidance

This section provides detailed implementation guidance for the US Core Profile to support implementation and certification.

  • This profile and the US Core Observation ADI Documentation Profile meet the U.S. Core Data for Interoperability (USCDI) Advance Directive Observation Data Element requirements.
  • This profile can communicate the contents of a Plan of Medical Orders (PMO) document, such as POLST, MOLST, or other state-specific forms. It is referenced by the [US Core PMO Service Request Profile], which represents an order based on the PMO document. PMO documents, typically stored as scanned images in EMRs/EHRs, follow the patient across care settings. Together, these profiles satisfy the USCDI's PMO Order Data Element requirements.
  • In addition to the Advance Directive Categories value set, other category schemes may be used to facilitate the sharing of health documents.
  • The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.content.attachment.url or the content as inline base64 encoded data using DocumentReference.content.attachment.data.
    • Although both are marked as Must Support, the Server system is not required to support an address and inline base64 encoded data, but SHALL support at least one of these elements.
    • The Client application SHALL support both elements.
    • The DocumentReference.content.attachment.url may refer to a FHIR Binary Resource (i.e., [base]/Binary/[id]), FHIR Document Bundle (i.e., [base]/Bundle/[id], or another endpoint).
      • If the referenced a document or file is hosted on a server outside the FHIR server, it should be securely accessible using the same authorization credentials that were used to access the FHIR server. This reduces complexity for the client and improves the user experience.
    • If there are multiple DocumentReference.content element repetitions, these SHALL all represent the same document in different formats or attachment metadata. The content element SHALL NOT contain different versions of the same content. For version handling, use multiple DocumentReferences with DocumentReference.relatesTo.
  • Every DocumentReference must have a responsible Organization. The organization responsible for the DocumentReference SHALL be present either in DocumentReference.custodian or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who or Provenance.agent.onBehalfOf.
    • Some systems may also expose the same organization in referenced Encounter in Encounter.serviceProvider.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 8.0.0:

  • The resource metadata has changed (description)

    • Formal Views of Profile Content

    Description Differentials, Snapshots, and other representations.

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension Content/Rules for all slices
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier SΣ 0..* Identifier Other identifiers for the document
    ... status ?!SΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
    Binding: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category SΣ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
    .... category:adi SΣ 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date SΣ 0..1 instant When this document reference was created
    ... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated the document
    ... content SΣ 1..* BackboneElement Document referenced
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SΣC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Example General: text/plain; charset=UTF-8, image/png
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SΣC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    .... format SΣ 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
    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()
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... Slices for extension Content/Rules for all slices
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... identifier S 0..* Identifier Other identifiers for the document
    ... status S 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
    Binding: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category S 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    .... category:adi S 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject S 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date S 0..1 instant When this document reference was created
    ... author S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated the document
    ... content S 1..* BackboneElement Document referenced
    .... attachment SC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... contentType S 0..1 code Mime type of the content, with charset etc.
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SC 0..1 url Uri where the data can be found
    .... format S 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 BindingsPurpose
    AllLanguages Max Binding
    ... 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
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
    ... identifier SΣ 0..* Identifier Other identifiers for the document
    ... status ?!SΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... docStatus Σ 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: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category SΣ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
    .... category:adi SΣ 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date SΣ 0..1 instant When this document reference was created
    ... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated 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 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 Σ 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 SΣC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Example General: text/plain; charset=UTF-8, image/png
    ..... language Σ 0..1 code Human language of the content (BCP-47)
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding

    Example General: en-AU
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SΣC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    ..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
    ..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
    ..... title Σ 0..1 string Label to display in place of the data
    Example General: Official Corporate Logo
    ..... creation Σ 0..1 dateTime Date attachment was first created
    .... format SΣ 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)
    ... context Σ 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 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 Σ 0..1 Period Time of service that is being documented
    .... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
    Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
    .... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
    Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
    .... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
    .... related 0..* Reference(Resource) Related identifiers or resources

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
    DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
    DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
    DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5
    DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
    DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
    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()
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
    ... Slices for extension Content/Rules for all slices
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... identifier SΣ 0..* Identifier Other identifiers for the document
    ... status ?!SΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
    Binding: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category SΣ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
    .... category:adi SΣ 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date SΣ 0..1 instant When this document reference was created
    ... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated the document
    ... content SΣ 1..* BackboneElement Document referenced
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SΣC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Example General: text/plain; charset=UTF-8, image/png
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SΣC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    .... format SΣ 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
    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()
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()

    Differential View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... Slices for extension Content/Rules for all slices
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... identifier S 0..* Identifier Other identifiers for the document
    ... status S 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
    Binding: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category S 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    .... category:adi S 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject S 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date S 0..1 instant When this document reference was created
    ... author S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated the document
    ... content S 1..* BackboneElement Document referenced
    .... attachment SC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... contentType S 0..1 code Mime type of the content, with charset etc.
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SC 0..1 url Uri where the data can be found
    .... format S 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)

    doco Documentation for this format

    Terminology Bindings (Differential)

    Path Status Usage ValueSet Version Source
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5

    Constraints

    Id Grade Path(s) Description Expression
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()

    Snapshot ViewView

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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 BindingsPurpose
    AllLanguages Max Binding
    ... 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
    ... Slices for extension 0..* Extension Extension
    Slice: Unordered, Open by value:url
    .... extension:authenticationTime S 0..1 dateTime Authentication Time
    URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-authentication-time
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
    ... identifier SΣ 0..* Identifier Other identifiers for the document
    ... status ?!SΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... docStatus Σ 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: Advance Healthcare Directive Document Types Grouper . (extensible): Advance Directives Content Type
    ... Slices for category SΣ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
    .... category:adi SΣ 0..* CodeableConcept Categorization of ADI document"
    Binding: Advance Healthcare Directive Categories LOINC . (required): Advance Healthcare Directive Categories Grouper. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
    ... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | US Core Device Profile) Who/what is the subject of the document
    ... date SΣ 0..1 instant When this document reference was created
    ... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile) Who and/or what authored the document
    ... authenticator S 0..1 Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core PractitionerRole Profile) Who/what authenticated 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 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 Σ 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 SΣC 1..1 Attachment Where to access the document
    Constraints: us-core-6
    ..... id 0..1 string Unique id for inter-element referencing
    ..... extension 0..* Extension Additional content defined by implementations
    Slice: Unordered, Open by value:url
    ..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Example General: text/plain; charset=UTF-8, image/png
    ..... language Σ 0..1 code Human language of the content (BCP-47)
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding

    Example General: en-AU
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ..... url SΣC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    ..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
    ..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
    ..... title Σ 0..1 string Label to display in place of the data
    Example General: Official Corporate Logo
    ..... creation Σ 0..1 dateTime Date attachment was first created
    .... format SΣ 0..1 Coding Format/content rules for the document
    Binding: HL7FormatCodes (2.1.0) (extensible)
    ... context Σ 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 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 Σ 0..1 Period Time of service that is being documented
    .... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
    Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
    .... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
    Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
    .... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
    .... related 0..* Reference(Resource) Related identifiers or resources

    doco Documentation for this format

    Terminology Bindings

    Path Status Usage ValueSet Version Source
    DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
    DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
    DocumentReference.type Base extensible Advance Healthcare Directive Document Types Grouper . 📦20250407 VSAC v0.23
    DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
    DocumentReference.category:adi Base required Advance Healthcare Directive Categories LOINC . 📦20250402 VSAC v0.23
    DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
    DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
    DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
    DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
    DocumentReference.content.​format Base extensible HL7 ValueSet of Format Codes for use with Document Sharing 📍2.1.0 THO v6.5
    DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.5
    DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
    DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

    Constraints

    Id Grade Path(s) Description Expression
    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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
    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()
    us-core-6 error DocumentReference.content.attachment DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. url.exists() or data.exists()

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Quick Start

    Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile's information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

    • See the Search Syntax section for a description of the US Core search syntax.
    • See the General Requirements section for additional rules and expectations when a Server requires status parameters.
    • See the General Guidance section for additional guidance on searching for multiple patients.

    Mandatory Search Parameters:

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

    1. SHALL support both read DocumentReference by id AND DocumentReference search using the _id search parameter:

      GET [base]/DocumentReference/[id] or GET [base]/DocumentReference?_id=[id]

      Example:

      1. GET [base]/DocumentReference/2169591
      2. GET [base]/DocumentReference?_id=2169591

      Implementation Notes: Fetches a single DocumentReference. The document itself is represented as a base64 encoded binary data element or retrieved using the link provided by the resource. If the document is a relative link to a Binary resource like a resource reference, it can be subsequently retrieved using: GET [base]/Binary/[id]. (how to search by the logical id of the resource)

    2. SHALL support searching for all documentreferences for a patient using the patient search parameter:

      GET [base]/DocumentReference?patient={Type/}[id]

      Example:

      1. GET [base]/DocumentReference?patient=1137192

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient. See the implementation notes above for how to access the actual document. (how to search by reference)

    3. SHALL support searching using the combination of the patient and category search parameters:

      GET [base]/DocumentReference?patient={Type/}[id]&category={system|}[code]

      Example:

      1. GET [base]/DocumentReference?patient=1235541&category=http://loinc.org|42348-3

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = "42348-3". See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

    4. SHALL support searching using the combination of the patient and category and date search parameters:
      • including support for these date comparators: gt,lt,ge,le
      • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

      GET [base]/DocumentReference?patient={Type/}[id]&category={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/DocumentReference?patient=1235541&category=http://loinc.org|42348-3&date=ge2020-01-01T00:00:00Z

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = "42348-3" and date. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)

    5. SHALL support searching using the combination of the patient and type search parameters:

      GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]

      Example:

      1. GET [base]/DocumentReference?patient=1316024&type=http://loinc.org|84095-9

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

    Optional Search Parameters:

    The following search parameter combinations SHOULD be supported:

    1. SHOULD support searching using the combination of the patient and status search parameters:
      • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

      GET [base]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

      Example:

      1. GET [base]/DiagnosticReport?patient=1137192&status=completed

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and status. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

    2. SHOULD support searching using the combination of the patient and type and period search parameters:
      • including support for these period comparators: gt,lt,ge,le
      • including optional support for AND search on period (e.g.period=[date]&period=[date]]&...)

      GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}

      Example:

      1. GET [base]/DocumentReference?patient=2169591&type=http://loinc.org|84095-9&period=ge2020-01-01T00:00:00Z

      Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and period. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)