Scalable Consent Management, published by HL7 International / Community Based Collaborative Care. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-consent-management/ and changes regularly. See the Directory of published versions
Official URL: http://hl7.org/fhir/us/consent-management/StructureDefinition/FASTConsentDocumentReference | Version: 0.1.0 | |||
Standards status: Trial-use | Maturity Level: 1 | Computable Name: FASTConsentDocumentReference |
This profile captures a print-friendly version of the consent.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDocumentReferenceProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | 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 | (USCDI) Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
type | SΣ | 1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:uscore | Σ | 0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | (USCDI) When this document reference was created | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | (USCDI) Who and/or what authored the document | ||||
content | SΣ | 1..* | BackboneElement | (USCDI) Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | (USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
contentType | SΣ | 0..1 | code | (USCDI) 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 | (USCDI) Data inline, base64ed | ||||
url | SΣC | 0..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
format | SΣ | 0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | (USCDI) Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | S | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Context of the document content | ||||
period | SΣ | 0..1 | Period | (USCDI) Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | 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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..* | Identifier | (USCDI) Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | (USCDI) 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 | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:uscore | Σ | 0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | (USCDI) 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 | Device) | (USCDI) 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 | 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 | (USCDI) 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 | (USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
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 | (USCDI) 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.
Example General: en-AU | ||||
data | SC | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
url | SΣC | 0..1 | url | (USCDI) 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 | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | (USCDI) 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 | S | 0..1 | Reference(US Core Encounter Profile) | (USCDI) 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 | SΣ | 0..1 | Period | (USCDI) 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 | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
This structure is derived from USCoreDocumentReferenceProfile
Differential View
This structure is derived from USCoreDocumentReferenceProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | 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 | (USCDI) Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
type | SΣ | 1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:uscore | Σ | 0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | (USCDI) When this document reference was created | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | (USCDI) Who and/or what authored the document | ||||
content | SΣ | 1..* | BackboneElement | (USCDI) Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | (USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
contentType | SΣ | 0..1 | code | (USCDI) 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 | (USCDI) Data inline, base64ed | ||||
url | SΣC | 0..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
format | SΣ | 0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | (USCDI) Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | S | 0..1 | Reference(US Core Encounter Profile) | (USCDI) Context of the document content | ||||
period | SΣ | 0..1 | Period | (USCDI) Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | 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.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..* | Identifier | (USCDI) Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | (USCDI) 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 | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
Slices for category | SΣ | 1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
category:uscore | Σ | 0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | (USCDI) 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 | Device) | (USCDI) 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 | 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 | (USCDI) 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 | (USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
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 | (USCDI) 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.
Example General: en-AU | ||||
data | SC | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
url | SΣC | 0..1 | url | (USCDI) 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 | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | (USCDI) 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 | S | 0..1 | Reference(US Core Encounter Profile) | (USCDI) 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 | SΣ | 0..1 | Period | (USCDI) 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 | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron