International Patient Access
1.1.0 - STU1

International Patient Access, published by HL7 International / Patient Care. This guide is not an authorized publication; it is the continuous build for version 1.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-ipa/ and changes regularly. See the Directory of published versions

## Resource Profile: IPA-DocumentReference

Official URL: http://hl7.org/fhir/uv/ipa/StructureDefinition/ipa-documentreference | Version: 1.1.0
Standards status: Trial-use | Computable Name: IPADocumentReference
Copyright/Legal: Used by permission of HL7 International all rights reserved Creative Commons License

Minimum expectations for a DocumentReference resource when accessed via a International Patient Access API

### 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

Usage:

- Examples for this Resource Profile: DocumentReference/USClinicalNoteExample1
- CapabilityStatements using this Resource Profile: International Patient Access Client CapabilityStatement and International Patient Access Server CapabilityStatement

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
type | SO Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO Σ | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO Σ | 0..1 | instant | When this document reference was created ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
author | SO Σ | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
content | SO Σ | 1..* | BackboneElement | Document referenced ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment | SO Σ C | 1..1 | Attachment | Where to access the document ele-1: All FHIR elements must have a @value or children ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
contentType | SO Σ | 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. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
data | SO | 0..1 | base64Binary | Data inline, base64ed ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO Σ | 0..1 | url | Uri where the data can be found ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/logo-small.png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO Σ | 0..1 | BackboneElement | Clinical context of document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
period | SO Σ | 0..1 | Period | Time of service that is being documented ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.type | preferred | DocumentTypeValueSet `http://hl7.org/fhir/ValueSet/c80-doc-typecodes` from the FHIR Standard
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` from the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` from the FHIR Standard
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard

#### 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

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
status | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
type | SO | 0..1 | CodeableConcept | Kind of document (LOINC if possible)
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO | 0..* | CodeableConcept | Categorization of document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | Server
author | SO | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
attachment | SO C | 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.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
contentType | SO | 1..1 | code | Mime type of the content, with charset etc.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
data | SO | 0..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO | 0..1 | url | Uri where the data can be found
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
format | SO | 0..1 | Coding | Format/content rules for the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
encounter | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
period | SO | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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
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 | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | SO Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO Σ | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | Server
author | SO Σ | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
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 | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 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
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO | 0..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | URI
DocumentReference.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | preferred | DocumentTypeValueSet `http://hl7.org/fhir/ValueSet/c80-doc-typecodes` from the FHIR Standard
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` from the FHIR Standard
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` from the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` from the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` from the FHIR Standard
DocumentReference.content.attachment.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

#### 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)

Key Elements View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
type | SO Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO Σ | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO Σ | 0..1 | instant | When this document reference was created ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
author | SO Σ | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
content | SO Σ | 1..* | BackboneElement | Document referenced ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment | SO Σ C | 1..1 | Attachment | Where to access the document ele-1: All FHIR elements must have a @value or children ipa-doc-1: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
contentType | SO Σ | 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. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
data | SO | 0..1 | base64Binary | Data inline, base64ed ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO Σ | 0..1 | url | Uri where the data can be found ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/logo-small.png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO Σ | 0..1 | BackboneElement | Clinical context of document ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
encounter | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
period | SO Σ | 0..1 | Period | Time of service that is being documented ele-1: All FHIR elements must have a @value or children
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.type | preferred | DocumentTypeValueSet `http://hl7.org/fhir/ValueSet/c80-doc-typecodes` from the FHIR Standard
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` from the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` from the FHIR Standard
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard

#### 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 | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
type | SO | 0..1 | CodeableConcept | Kind of document (LOINC if possible)
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO | 0..* | CodeableConcept | Categorization of document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | Server
author | SO | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
attachment | SO C | 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.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
contentType | SO | 1..1 | code | Mime type of the content, with charset etc.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
data | SO | 0..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO | 0..1 | url | Uri where the data can be found
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
format | SO | 0..1 | Coding | Format/content rules for the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
encounter | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
period | SO | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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() |

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 | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | SO Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
category | SO Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
subject | SO Σ | 1..1 | Reference(IPA-Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | Server
author | SO Σ | 0..* | Reference(IPA-Practitioner | IPA-PractitionerRole | Organization | Device | IPA-Patient | RelatedPerson) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | Server
SHOULD:handle | Client
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 | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ C | 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.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 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
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO | 0..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
url | SO Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO | 0..1 | Reference(Encounter | EpisodeOfCare) | Context of the document content
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:populate-if-known | Server
SHALL:handle | Client
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 | URI
DocumentReference.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | preferred | DocumentTypeValueSet `http://hl7.org/fhir/ValueSet/c80-doc-typecodes` from the FHIR Standard
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` from the FHIR Standard
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` from the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` from the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` from the FHIR Standard
DocumentReference.content.attachment.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

#### 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)

Other representations of profile: CSV, Excel, Schematron