Medicolegal Death Investigation (MDI) FHIR Implementation Guide
2.0.1-cibuild - ci-build
Medicolegal Death Investigation (MDI) FHIR Implementation Guide
2.0.1-cibuild - ci-build
Medicolegal Death Investigation (MDI) FHIR Implementation Guide, published by HL7 International / Public Health. This guide is not an authorized publication; it is the continuous build for version 2.0.1-cibuild built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/fhir-mdi-ig/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org/fhir/us/mdi/StructureDefinition/DocumentReference-mdi-report | Version: 2.0.1-cibuild | |||
| Active as of 2024-11-22 | Computable Name: DocumentReferenceMDIReport | |||
| Other Identifiers: OID:2.16.840.1.113883.4.642.40.11.42.8 | ||||
This DocumentReference profile constrains the US Core DocumentReference Profile to support exchanging death investigation documents, such as an Autopsy Report or Investigator’s Narrative. The content may be included as inline base64 encoded data or be provided by direct reference (e.g., URL). The document type is required and is constrained by US Core to a LOINC value whose SCALE is DOC in the LOINC database or is the HL7 v3 Code System NullFlavor concept 'unknown'.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDocumentReferenceProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |
  type |
1..1 | CodeableConcept | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. | |
 category |
1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text | |
  text |
0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
 identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
  Slices for category |
SΣ | 1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
  category:All Slices |
Content/Rules for all slices | |||||||
  text |
Σ | 0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | ||||
 category:us-core |
SΣ | 0..* | CodeableConcept | 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. | ||||
 subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile) | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
| contentType |
SΣ | 0..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 |
SC | 0..1 | base64Binary | Data inline, base64ed | ||||
| url |
SΣC | 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 (extensible) | ||||
| 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(US Core Encounter Profile) | Context of the document content | ||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-statusfrom the FHIR Standard | ||||
| DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.category:us-core | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | 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 | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:All Slices |
Content/Rules for all slices | |||||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text |
Σ | 0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | ||||
| category:us-core |
SΣ | 0..* | CodeableConcept | 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. | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | 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) | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 0..1 | code | 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 | Data inline, base64ed | ||||
| url |
SΣC | 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 (extensible) | ||||
| 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(US Core Encounter Profile) | 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-statusfrom the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.category:us-core | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from USCoreDocumentReferenceProfile
Differential View
This structure is derived from USCoreDocumentReferenceProfile
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |
| type |
1..1 | CodeableConcept | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. | |
| category |
1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text | |
| text |
0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | |
| Documentation for this format | ||||
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:All Slices |
Content/Rules for all slices | |||||||
| text |
Σ | 0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | ||||
| category:us-core |
SΣ | 0..* | CodeableConcept | 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. | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(US Core Practitioner Profile) | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
| contentType |
SΣ | 0..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 |
SC | 0..1 | base64Binary | Data inline, base64ed | ||||
| url |
SΣC | 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 (extensible) | ||||
| 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(US Core Encounter Profile) | Context of the document content | ||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-statusfrom the FHIR Standard | ||||
| DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.category:us-core | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | 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 | If LOINC code for type is not available, use HL7 v3 Code System NullFlavor (http://terminology.hl7.org/CodeSystem/v3-NullFlavor) code=UNK, display=unknown 'unknown'. Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
| Slices for category |
SΣ | 1..* | CodeableConcept | Reference a terminology (code system & code) or use text to describe the document category. A category is required, so if none is available use NullFlavor Other code and describe category in text Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| category:All Slices |
Content/Rules for all slices | |||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| coding |
Σ | 0..* | Coding | Code defined by a terminology system | ||||
| text |
Σ | 0..1 | string | If no system/code is available, use NullFLavor Other code, and describe the document category in text | ||||
| category:us-core |
SΣ | 0..* | CodeableConcept | 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. | ||||
| subject |
SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | 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) | 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 us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣ | 0..1 | code | 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 | Data inline, base64ed | ||||
| url |
SΣC | 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 (extensible) | ||||
| 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(US Core Encounter Profile) | 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-statusfrom the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.category:us-core | required | USCoreDocumentReferenceCategoryhttp://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron
IG © 2023+ HL7 International / Public Health. Package hl7.fhir.us.mdi#2.0.1-cibuild based on FHIR 4.0.1. Generated 2024-11-22
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