Medicolegal Death Investigation (MDI) FHIR Implementation Guide
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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 2.0.0-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

Resource Profile: DocumentReference - MDI Report

Official URL: http://hl7.org/fhir/us/mdi/StructureDefinition/DocumentReference-mdi-report Version: 2.0.0-cibuild
Active as of 2024-10-07 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:

Formal Views of Profile Content

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

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) 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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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(5.0.1)) 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(5.0.1)) 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(5.0.1)) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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(5.0.1)) 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(5.0.1) S | US Core Organization Profile(5.0.1) | US Core Patient Profile(5.0.1) | US Core PractitionerRole Profile(5.0.1) | 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.

Additional BindingsPurpose
AllLanguages Max Binding

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(5.0.1)) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

This structure is derived from USCoreDocumentReferenceProfile

Summary

Differential View

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) 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

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) 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
... 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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(5.0.1)) 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(5.0.1)) 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(5.0.1)) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings

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

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier 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'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... 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(5.0.1)) 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(5.0.1) S | US Core Organization Profile(5.0.1) | US Core Patient Profile(5.0.1) | US Core PractitionerRole Profile(5.0.1) | 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.

Additional BindingsPurpose
AllLanguages Max Binding

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(5.0.1)) 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

This structure is derived from USCoreDocumentReferenceProfile

Summary

 

Other representations of profile: CSV, Excel, Schematron