Mobile access to Health Documents (MHD)
5.0.0-prototype - ci-build International flag

Mobile access to Health Documents (MHD), published by IHE IT Infrastructure Technical Committee. This is not an authorized publication; it is the continuous build for version 5.0.0-prototype). This version is based on the current content of https://github.com/IHE/ITI.MHD/ and changes regularly. See the Directory of published versions

Resource Profile: MHD DocumentReference Minimal

Official URL: https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.Minimal.DocumentReference Version: 5.0.0-prototype
Active as of 2022-06-21 Computable Name: MinimalDocumentReference

Copyright/Legal: IHE http://www.ihe.net/Governance/#Intellectual_Property

A profile on the DocumentReference resource for MHD with minimal metadata constraints.

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 15 elements
Prohibited: 4 elements

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... meta
.... profile 0..*canonical(StructureDefinition)Profiles this resource claims to conform to
... modifierExtension 0..0
... masterIdentifier 1..1IdentifierMaster Version Specific Identifier
... identifier S0..*IdentifierOther identifiers for the document
... status 1..1codecurrent | superseded | entered-in-error
... docStatus 0..0
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S0..1CodeableConceptCategorization of document
... subject S0..1Reference(Patient)Who/what is the subject of the document
... date S0..1instantWhen this document reference was created
... author S0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo S0..*BackboneElementRelationships to other documents
.... code 1..1codereplaces | transforms | signs | appends
.... target 1..1Reference(DocumentReference)Target of the relationship
... description 0..1stringHuman-readable description
... securityLabel S0..*CodeableConceptDocument security-tags
... content 1..1BackboneElementDocument referenced
.... attachment
..... contentType 1..1codeMime type of the content, with charset etc.
..... language S0..1codeHuman language of the content (BCP-47)
..... data 0..0
..... url 1..1urlUri where the data can be found
..... size 0..1unsignedIntNumber of bytes of content (if url provided)
..... hash 0..1base64BinaryHash of the data (sha-1, base64ed)
..... title 0..1stringLabel to display in place of the data
..... creation S0..1dateTimeDate attachment was first created
.... format S0..1CodingFormat/content rules for the document
... context
.... encounter 0..0
.... event 0..*CodeableConceptMain clinical acts documented
.... period S0..1PeriodTime of service that is being documented
..... start 0..1dateTimeStarting time with inclusive boundary
..... end 0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... facilityType S0..1CodeableConceptKind of facility where patient was seen
.... practiceSetting S0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo S0..1Reference(Patient)Patient demographics from source
..... reference 0..1stringLiteral reference, Relative, internal or absolute URL
..... identifier 0..1IdentifierLogical reference, when literal reference is not known
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... masterIdentifier Σ1..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ0..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ0..1Reference(Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo SΣ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel SΣ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment Σ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType Σ1..1codeMime 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 SΣ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... url Σ1..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣI0..1dateTimeStarting time with inclusive boundary
..... end ΣI0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... facilityType S0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S0..1CodeableConceptAdditional 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 S0..1Reference(Patient)Patient demographics from source
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
..... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

..... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
..... display Σ0..1stringText alternative for the resource
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... identifier Σ0..*IdentifierOther identifiers for the document
... type Σ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ0..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ0..1Reference(Patient)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..1BackboneElementDocument referenced
.... attachment Σ1..1AttachmentWhere to access the document
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
..... creation Σ0..1dateTimeDate attachment was first created
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ0..1BackboneElementClinical context of document
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source

doco Documentation for this format

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 15 elements
Prohibited: 4 elements

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... meta
.... profile 0..*canonical(StructureDefinition)Profiles this resource claims to conform to
... modifierExtension 0..0
... masterIdentifier 1..1IdentifierMaster Version Specific Identifier
... identifier S0..*IdentifierOther identifiers for the document
... status 1..1codecurrent | superseded | entered-in-error
... docStatus 0..0
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S0..1CodeableConceptCategorization of document
... subject S0..1Reference(Patient)Who/what is the subject of the document
... date S0..1instantWhen this document reference was created
... author S0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo S0..*BackboneElementRelationships to other documents
.... code 1..1codereplaces | transforms | signs | appends
.... target 1..1Reference(DocumentReference)Target of the relationship
... description 0..1stringHuman-readable description
... securityLabel S0..*CodeableConceptDocument security-tags
... content 1..1BackboneElementDocument referenced
.... attachment
..... contentType 1..1codeMime type of the content, with charset etc.
..... language S0..1codeHuman language of the content (BCP-47)
..... data 0..0
..... url 1..1urlUri where the data can be found
..... size 0..1unsignedIntNumber of bytes of content (if url provided)
..... hash 0..1base64BinaryHash of the data (sha-1, base64ed)
..... title 0..1stringLabel to display in place of the data
..... creation S0..1dateTimeDate attachment was first created
.... format S0..1CodingFormat/content rules for the document
... context
.... encounter 0..0
.... event 0..*CodeableConceptMain clinical acts documented
.... period S0..1PeriodTime of service that is being documented
..... start 0..1dateTimeStarting time with inclusive boundary
..... end 0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... facilityType S0..1CodeableConceptKind of facility where patient was seen
.... practiceSetting S0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo S0..1Reference(Patient)Patient demographics from source
..... reference 0..1stringLiteral reference, Relative, internal or absolute URL
..... identifier 0..1IdentifierLogical reference, when literal reference is not known
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ0..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security Σ0..*CodingSecurity Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


.... tag Σ0..*CodingTags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... masterIdentifier Σ1..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ0..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ0..1Reference(Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo SΣ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel SΣ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment Σ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType Σ1..1codeMime 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 SΣ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... url Σ1..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣI0..1dateTimeStarting time with inclusive boundary
..... end ΣI0..1dateTimeEnd time with inclusive boundary, if not ongoing
.... facilityType S0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S0..1CodeableConceptAdditional 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 S0..1Reference(Patient)Patient demographics from source
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣI0..1stringLiteral reference, Relative, internal or absolute URL
..... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

..... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
..... display Σ0..1stringText alternative for the resource
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
DocumentReference.meta.securityextensibleAll Security Labels
DocumentReference.meta.tagexampleCommonTags
DocumentReference.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types
DocumentReference.content.attachment.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
DocumentReference.context.sourcePatientInfo.typeextensibleResourceType