AI Transparency on FHIR
1.0.0-current - STU1 Ballot
AI Transparency on FHIR
1.0.0-current - STU1 Ballot
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-current 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
| Official URL: http://hl7.org/fhir/uv/aitransparency/StructureDefinition/AI-InputPrompt | Version: 1.0.0-current | ||||
| Standards status: Trial-use | Maturity Level: 2 | Computable Name: AIInputPrompt | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.79.42.2 | |||||
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:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  DocumentReference |
0..* | DocumentReference | A reference to a document | |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
 identifier |
0..* | Identifier | Other identifiers for the document | |
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |
 type |
1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | |
   Slices for coding |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Closed by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
   coding:AIInputPrompt |
1..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 |
0..1 | string | Representation defined by the system | |
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| description |
0..1 | string | Human-readable description | |
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
  content:All Slices |
Content/Rules for all slices | |||
  modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
 attachment |
1..1 | Attachment | Where to access the document | |
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
 attachment |
1..1 | Attachment | Where to access the document | |
| contentType |
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 |
0..1 | base64Binary | Data inline, base64ed | |
 url |
0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | |
| Documentation for this format | ||||
| 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. |
| 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()
|
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| identifier |
0..* | Identifier | Other identifiers for the document | |
| type |
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 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| coding:AIInputPrompt |
1..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 | |
| description |
0..1 | string | Human-readable description | |
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |
| attachment |
||||
| contentType |
1..1 | code | Mime type of the content, with charset etc. Fixed Value: text/markdown | |
| data |
0..1 | base64Binary | Data inline, base64ed | |
| url |
0..1 | url | Uri where the data can be found | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation 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 |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
0..* | Identifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
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 |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Closed by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| coding:AIInputPrompt |
1..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 |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | |||||
 subject |
0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document | |||||
| date |
0..1 | instant | When this document reference was created | |||||
| author |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | Attachment | Where to access the document | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
 attachment |
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 |
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 |
0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | |||||
| data |
0..1 | base64Binary | Data inline, base64ed | |||||
| url |
0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | |||||
| size |
0..1 | unsignedInt | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
0..1 | dateTime | Date attachment was first created | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| context |
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 |
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 |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | 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 v7.4 |
| 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. |
| 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()
|
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element
Slices
This structure defines the following Slices:
Maturity: 2
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| identifier |
0..* | Identifier | Other identifiers for the document | |
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |
| type |
1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | |
| Slices for coding |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Closed by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| coding:AIInputPrompt |
1..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 |
0..1 | string | Representation defined by the system | |
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |
| description |
0..1 | string | Human-readable description | |
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| content:All Slices |
Content/Rules for all slices | |||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| attachment |
1..1 | Attachment | Where to access the document | |
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| attachment |
1..1 | Attachment | Where to access the document | |
| contentType |
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 |
0..1 | base64Binary | Data inline, base64ed | |
| url |
0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | |
| Documentation for this format | ||||
| 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. |
| 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
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| identifier |
0..* | Identifier | Other identifiers for the document | |
| type |
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 Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| coding:AIInputPrompt |
1..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 | |
| description |
0..1 | string | Human-readable description | |
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |
| attachment |
||||
| contentType |
1..1 | code | Mime type of the content, with charset etc. Fixed Value: text/markdown | |
| data |
0..1 | base64Binary | Data inline, base64ed | |
| url |
0..1 | url | Uri where the data can be found | |
| Documentation for this format | ||||
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation 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 |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
0..* | Identifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
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 |
1..* | Coding | Code defined by a terminology system Slice: Unordered, Closed by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| coding:AIInputPrompt |
1..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 |
0..1 | string | Representation defined by the system | |||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | |||||
| subject |
0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document | |||||
| date |
0..1 | instant | When this document reference was created | |||||
| author |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| Slices for content |
1..* | BackboneElement | Document referenced Slice: Unordered, Open by value:attachment.contentType Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| 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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | Attachment | Where to access the document | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| content:MarkdownFormat |
0..1 | BackboneElement | Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
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 |
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 |
0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | |||||
| data |
0..1 | base64Binary | Data inline, base64ed | |||||
| url |
0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | |||||
| size |
0..1 | unsignedInt | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
0..1 | dateTime | Date attachment was first created | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| context |
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 |
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 |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | 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 v7.4 |
| 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. |
| 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()
|
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements(1 nested mandatory element)
Must-Support: 7 elements
Fixed: 1 element
Slices
This structure defines the following Slices:
Maturity: 2
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ HL7 International / Electronic Health Records.
Package hl7.fhir.uv.aitransparency#1.0.0-current based on FHIR 4.0.1.
Generated
2026-10-06
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