US Behavioral Health Profiles Implementation Guide, published by . This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/us-behavioral-health-profiles/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• XML
• JSON
• TTL

Resource Profile: Mental Health Clinical Notes Profile

Usage:

• Examples for this Resource Profile: DocumentReference/mental-health-consult-note-example-1, DocumentReference/mental-health-discharge-summary-example-1, DocumentReference/mental-health-hx-physical-example-1, DocumentReference/mental-health-procedure-example-1 and DocumentReference/mental-health-progress-example-1

Formal Views of Profile Content

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

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

This structure is derived from USCoreDocumentReferenceProfile

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	USCoreDocumentReferenceProfile	A reference to a document
type		1..1	CodeableConcept	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG

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	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	SΣ	1..1	CodeableConcept	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category	SΣ	1..*	CodeableConcept	(USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore	Σ	0..*	CodeableConcept	(USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile)	(USCDI) Who and/or what authored the document
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	0..1	code	(USCDI) Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory http://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|4.0.1 from 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/formatcodes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

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. 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	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category	SΣ	1..*	CodeableConcept	(USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore	Σ	0..*	CodeableConcept	(USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)	(USCDI) Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document 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	(USCDI) Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from 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/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
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

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	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG

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	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	SΣ	1..1	CodeableConcept	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category	SΣ	1..*	CodeableConcept	(USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore	Σ	0..*	CodeableConcept	(USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile)	(USCDI) Who and/or what authored the document
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	0..1	code	(USCDI) Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory http://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|4.0.1 from 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/formatcodes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

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. 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	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	(USCDI) Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category	SΣ	1..*	CodeableConcept	(USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore	Σ	0..*	CodeableConcept	(USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)	(USCDI) Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document 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	(USCDI) Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	MentalHealthClinicalNoteTypes http://hl7.org/fhir/us/bhp/ValueSet/mental-health-clinical-note-types from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from 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/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
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

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