AI Transparency on FHIR, published by HL7 International / Electronic Health Records. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/aitransparency-ig/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: AI Input Prompt DocumentReference

A DocumentReference that contains an input prompt for an AI system. The Input Prompt is the information that is input into the AI system to produce an output. This DocumentReference can be used to capture the Input Prompt that was used with a given AI system, and can be referenced from the Provenance that tracks the usage of the AI system. The AI Prompt is typically encoded in markdown, but does not need to be. This DocumentReference would be referenced in the Provenance as the input to an Activity that represents the usage of the AI system, and the AIDevice would be referenced as the agent in that Provenance. This allows for traceability from the output back to the Input Prompt and the AI system that produced it.

Usages:

• Refer to this Profile: AI Provenance
• Examples for this Profile: DocumentReference/Input-Prompt-create-patient and DocumentReference/Input-Prompt-lorem-ipsum

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description Differentials, Snapshots, and other representations.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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
identifier	SΣ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.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: DocumentTypeValueSet (preferred): Precise type of clinical document.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	SΣ	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
userSelected		0..1	boolean	If this coding was chosen directly by the user
description	SΣ	0..1	string	Human-readable description
Slices for content	Σ	1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
content:MarkdownFormat	Σ	0..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
contentType	SΣ	1..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. Fixed Value: text/markdown
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
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	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.contentType	Base	required	MimeType	📍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()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	Other identifiers for the document
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	S	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
description	S	0..1	string	Human-readable description
Slices for content		1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:MarkdownFormat		0..1	BackboneElement	Document referenced
attachment
contentType	S	1..1	code	Mime type of the content, with charset etc. Fixed Value: text/markdown
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 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	?!	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	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
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: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	SΣ	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
userSelected		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: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	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	SΣ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for content	Σ	1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:All Slices				Content/Rules for all slices
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
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
content:MarkdownFormat	Σ	0..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
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	1..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. Fixed Value: text/markdown
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	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	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
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: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	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	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📍3.0.0	THO v7.1
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()

Summary

Mandatory: 3 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.type.coding (Closed)
• The element 1 is sliced based on the value of DocumentReference.content

Maturity: 2

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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
identifier	SΣ	0..*	Identifier	Other identifiers for the document
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: DocumentTypeValueSet (preferred): Precise type of clinical document.
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	SΣ	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
userSelected		0..1	boolean	If this coding was chosen directly by the user
description	SΣ	0..1	string	Human-readable description
Slices for content	Σ	1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
content:MarkdownFormat	Σ	0..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
contentType	SΣ	1..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. Fixed Value: text/markdown
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
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	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.contentType	Base	required	MimeType	📍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()

Differential View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	Other identifiers for the document
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	S	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
description	S	0..1	string	Human-readable description
Slices for content		1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:MarkdownFormat		0..1	BackboneElement	Document referenced
attachment
contentType	S	1..1	code	Mime type of the content, with charset etc. Fixed Value: text/markdown
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
Documentation for this format

Snapshot ViewView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
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 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	?!	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	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
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: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Closed by value:$this
coding:AIInputPrompt	SΣ	1..*	Coding	Code defined by a terminology system Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://hl7.org/fhir/uv/aitransparency/CodeSystem/AIinputsCS
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: AIInputPrompt
display		1..1	string	Representation defined by the system Fixed Value: AI Input Prompt
userSelected		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: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	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	SΣ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for content	Σ	1..*	BackboneElement	Document referenced Slice: Unordered, Open by value:attachment.contentType
content:All Slices				Content/Rules for all slices
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
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
content:MarkdownFormat	Σ	0..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
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	1..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. Fixed Value: text/markdown
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	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	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
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: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	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	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:MarkdownFormat.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📍3.0.0	THO v7.1
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()

Summary

Mandatory: 3 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.type.coding (Closed)
• The element 1 is sliced based on the value of DocumentReference.content

Maturity: 2

Other representations of profile: CSV, Excel, Schematron