Scalable Consent Management
0.1.0 - ci-build United States of America flag

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

Resource Profile: FASTConsentDocumentReference

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:

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

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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.

Additional BindingsPurpose
AllLanguages Max Binding

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime 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.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

Maturity: 1

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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.

Additional BindingsPurpose
AllLanguages Max Binding

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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime 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.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

Maturity: 1

 

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