Scalable Consent Management
0.1.0 - ci-build
Scalable Consent Management
0.1.0 - ci-build
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/FASTDocumentReference | Version: 0.1.0 | |||
| Standards status: Trial-use | Maturity Level: 1 | Computable Name: FASTDocumentReference | ||
This profile records non-structured documentation that records a patient's consent.
The following data elements must always be present or must be supported if the data is present in the sending system Must Support. They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.
Along with the rules for a US Core DocumentReference,
Each DocumentReference Must Have:
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  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?!SΣ | 1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |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: LOINC Consent Document Types (required) |
  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 |
 category:ConsentDocumentCategory |
SΣ | 1..1 | CodeableConcept | (USCDI) Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following |
  id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
  coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
 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://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |
| 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 | |
 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 |
| 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 Constraints: us-core-6 |
| 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 | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category:ConsentDocumentCategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code 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()
|
| 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
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |
 type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: LOINC Consent Document Types (required) | |
| Slices for category |
Content/Rules for all slices | |||
| category:ConsentDocumentCategory |
S | 1..1 | CodeableConcept | (USCDI) Categorization of document Required Pattern: At least the following |
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | (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: LOINC Consent Document Types (required) | ||||
| 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 | ||||
| category:ConsentDocumentCategory |
SΣ | 1..1 | CodeableConcept | (USCDI) Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| 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://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |||||
| 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 | |||||
| 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 Constraints: us-core-6 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 0..1 | code | (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: ActCode (3.0.0) (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 | 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 | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category:ConsentDocumentCategory | 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.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v6.5 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
This structure is derived from USCoreDocumentReferenceProfile
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| 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: LOINC Consent Document Types (required) |
| 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 |
| category:ConsentDocumentCategory |
SΣ | 1..1 | CodeableConcept | (USCDI) Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following |
| id |
0..1 | string | Unique id for inter-element referencing | |
| extension |
0..* | Extension | Additional content defined by implementations | |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| 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://loinc.org | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |
| 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 | |
| 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 |
| 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 Constraints: us-core-6 |
| 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 | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category:ConsentDocumentCategory | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code 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()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
Differential View
This structure is derived from USCoreDocumentReferenceProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |
| type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: LOINC Consent Document Types (required) | |
| Slices for category |
Content/Rules for all slices | |||
| category:ConsentDocumentCategory |
S | 1..1 | CodeableConcept | (USCDI) Categorization of document Required Pattern: At least the following |
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| 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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | (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: LOINC Consent Document Types (required) | ||||
| 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 | ||||
| category:ConsentDocumentCategory |
SΣ | 1..1 | CodeableConcept | (USCDI) Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Required Pattern: At least the following | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||
| 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://loinc.org | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 57016-8 | |||||
| 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 | |||||
| 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 Constraints: us-core-6 | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 0..1 | code | (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: ActCode (3.0.0) (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 | 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 | required | LOINC Consent Document Types | 📦0.1.0 | This IG |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category:ConsentDocumentCategory | 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.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v6.5 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ HL7 International / Community Based Collaborative Care. Package hl7.fhir.us.consent-management#0.1.0 based on FHIR 4.0.1. Generated 2025-10-08
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