Mandatory and Must Support Data Elements

The following data elements must always be present (in other words, mandatory resource properties where the minimum cardinality is 1) or must be supported (Must Support definition). Servers cannot restrict access to mandatory elements when authorizing an application. However, servers may choose to provide additional information or may be required to do so by national or other profiles that apply to the server’s context.

Each DocumentReference SHALL have:

• a status
• a patient
• one or more documents referenced (content) which is either a URL where the data can be found or inline data or both
• the MIME type (i.e. contentType) of the document

Applications must also support:

• a code describing the type of document
• one or more category codes used to group document types
• date and time the reference was created
• one or more authors
• a code identifying the specific details about the format of the document — over and above the content’s MIME type
• the patient encounter that is being referenced
• clinically relevant date

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status	S	1..1	code	current | superseded | entered-in-error
type	S	0..1	CodeableConcept	Kind of document (LOINC if possible)
category	S	0..*	CodeableConcept	Categorization of document
subject	S	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	S	0..1	instant	When this document reference was created
author	S	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	Who and/or what authored the document
content	S	1..*	BackboneElement	Document referenced
attachment	SC	1..1	Attachment	Where to access the document ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	S	1..1	code	Mime type of the content, with charset etc.
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
format	S	0..1	Coding	Format/content rules for the document
context	S	0..1	BackboneElement	Clinical context of document
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	Context of the document content
period	S	0..1	Period	Time of service that is being documented
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	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..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	SΣ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	Who and/or what authored the document
content	SΣ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	Where to access the document ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	SΣ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	Context of the document content
period	SΣ	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	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..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
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	Σ	0..*	Identifier	Other identifiers for the document
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	SΣ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	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	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	Where to access the document ipa-doc-1: 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	1..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. 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 Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	SΣ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	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	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	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 DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status	S	1..1	code	current | superseded | entered-in-error
type	S	0..1	CodeableConcept	Kind of document (LOINC if possible)
category	S	0..*	CodeableConcept	Categorization of document
subject	S	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	S	0..1	instant	When this document reference was created
author	S	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	Who and/or what authored the document
content	S	1..*	BackboneElement	Document referenced
attachment	SC	1..1	Attachment	Where to access the document ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	S	1..1	code	Mime type of the content, with charset etc.
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
format	S	0..1	Coding	Format/content rules for the document
context	S	0..1	BackboneElement	Clinical context of document
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	Context of the document content
period	S	0..1	Period	Time of service that is being documented
Documentation for this format

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	SΣ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	Who and/or what authored the document
content	SΣ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	Where to access the document ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	SΣ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	Context of the document content
period	SΣ	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	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..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
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	Σ	0..*	Identifier	Other identifiers for the document
status	?!SΣ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	SΣ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(IPA-Patient)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	0..*	Reference(IPA-Practitioner | IPA-PractitionerRole | IPA-Patient)	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	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	Where to access the document ipa-doc-1: 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	1..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. 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 Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	SΣ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(Encounter | EpisodeOfCare)	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	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
ipa-doc-1	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 DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 15 elements

Structures

This structure refers to these other structures:

• IPA-Patient (http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-patient)
• IPA-Practitioner (http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-practitioner)
• IPA-PractitionerRole (http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-practitionerrole)