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 Comprehensive UnContained References Option

Official URL: https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.UnContained.Comprehensive.DocumentReference Version: 5.0.0-prototype
Active as of 2022-07-22 Computable Name: UnContainedComprehensiveDocumentReference

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

A profile on the DocumentReference resource for MHD with Comprehensive Metadata Option but without a requirement for contained author, authenticator, or sourcePatientInfo.

Usage:

Formal Views of Profile Content

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

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 11 elements

This structure is derived from MinimalDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference MinimalDocumentReference
... type 1..1CodeableConceptKind of document (LOINC if possible)
... category 1..1CodeableConceptCategorization of document
... subject 1..1Reference(Patient)Who/what is the subject of the document
... securityLabel 1..*CodeableConceptDocument security-tags
... content
.... attachment
..... language 1..1codeHuman language of the content (BCP-47)
..... creation 1..1dateTimeDate attachment was first created
.... format 1..1CodingFormat/content rules for the document
... context 1..1BackboneElementClinical context of document
.... facilityType 1..1CodeableConceptKind of facility where patient was seen
.... practiceSetting 1..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1Reference(Patient)Patient demographics from source

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MinimalDocumentReferenceA 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 SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..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 SΣ1..*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 SΣ1..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 SΣ1..1dateTimeDate attachment was first created
.... format SΣ1..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ1..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 S1..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S1..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 S1..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..*MinimalDocumentReferenceA reference to a document
... identifier Σ0..*IdentifierOther identifiers for the document
... type Σ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ1..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 Σ1..*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 Σ1..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
..... creation Σ1..1dateTimeDate attachment was first created
.... format Σ1..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ1..1BackboneElementClinical context of document
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 1..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

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

doco Documentation for this format

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 11 elements

Differential View

This structure is derived from MinimalDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference MinimalDocumentReference
... type 1..1CodeableConceptKind of document (LOINC if possible)
... category 1..1CodeableConceptCategorization of document
... subject 1..1Reference(Patient)Who/what is the subject of the document
... securityLabel 1..*CodeableConceptDocument security-tags
... content
.... attachment
..... language 1..1codeHuman language of the content (BCP-47)
..... creation 1..1dateTimeDate attachment was first created
.... format 1..1CodingFormat/content rules for the document
... context 1..1BackboneElementClinical context of document
.... facilityType 1..1CodeableConceptKind of facility where patient was seen
.... practiceSetting 1..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1Reference(Patient)Patient demographics from source

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MinimalDocumentReferenceA 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 SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..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 SΣ1..*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 SΣ1..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 SΣ1..1dateTimeDate attachment was first created
.... format SΣ1..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ1..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 S1..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting S1..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 S1..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