Mobile access to Health Documents (MHD)
4.2.3-current - ci-build International flag

Mobile access to Health Documents (MHD), published by IHE IT Infrastructure Technical Committee. This guide is not an authorized publication; it is the continuous build for version 4.2.3-current built by the FHIR (HL7® FHIR® Standard) CI Build. 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: 4.2.3-current
Active as of 2025-10-06 Computable Name: UnContainedComprehensiveDocumentReference

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

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... masterIdentifier Σ 1..1 UniqueIdIdentifier Master Version Specific Identifier
... Slices for identifier SΣ 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:use
.... identifier:entryUUID SΣ 0..* EntryUUIDIdentifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: MHD DocumentReference status codes (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 1..1 CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Who and/or what authored the document
... relatesTo SΣ 0..* BackboneElement Relationships to other documents
.... 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
... securityLabel SΣ 1..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content Σ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Where to access the document
..... contentType Σ 1..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 SΣ 1..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url Σ 1..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... creation SΣ 1..1 dateTime Date attachment was first created
.... format SΣ 1..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 1..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... period SΣ 0..1 Period Time of service that is being documented
.... facilityType S 1..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 1..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 S 1..1 Reference(Patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required MHD DocumentReference status codes 📦4.2.3-current This IG
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred IHE ValueSet of Format Codes for use with Document Sharing 📦1.4.0 IHE FormatCode Vocabulary v1.4
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

This structure is derived from MinimalDocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... type 1..1 CodeableConcept Kind of document (LOINC if possible)
... category 1..1 CodeableConcept Categorization of document
... subject 1..1 Reference(Patient) Who/what is the subject of the document
... securityLabel 1..* CodeableConcept Document security-tags
... content
.... attachment
..... language 1..1 code Human language of the content (BCP-47)
..... creation 1..1 dateTime Date attachment was first created
.... format 1..1 Coding Format/content rules for the document
... context 1..1 BackboneElement Clinical context of document
.... facilityType 1..1 CodeableConcept Kind of facility where patient was seen
.... practiceSetting 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1 Reference(Patient) Patient demographics from source

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags 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 ?!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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... masterIdentifier Σ 1..1 UniqueIdIdentifier Master Version Specific Identifier
... Slices for identifier SΣ 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:use
.... identifier:entryUUID SΣ 0..* EntryUUIDIdentifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: MHD DocumentReference status codes (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 1..1 CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) 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 SΣ 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 SΣ 1..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content Σ 1..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 Σ 1..1 Attachment Where to access the document
..... 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 Σ 1..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 SΣ 1..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url Σ 1..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 SΣ 1..1 dateTime Date attachment was first created
.... format SΣ 1..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 1..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 0..* Reference(Encounter | EpisodeOfCare) 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 1..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 1..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 S 1..1 Reference(Patient) Patient demographics from source
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.status Base required MHD DocumentReference status codes 📦4.2.3-current This IG
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred IHE ValueSet of Format Codes for use with Document Sharing 📦1.4.0 IHE FormatCode Vocabulary v1.4
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.5
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​sourcePatientInfo.type Base extensible ResourceType 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 11 elements

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... masterIdentifier Σ 1..1 UniqueIdIdentifier Master Version Specific Identifier
... Slices for identifier SΣ 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:use
.... identifier:entryUUID SΣ 0..* EntryUUIDIdentifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: MHD DocumentReference status codes (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 1..1 CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Who and/or what authored the document
... relatesTo SΣ 0..* BackboneElement Relationships to other documents
.... 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
... securityLabel SΣ 1..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content Σ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Where to access the document
..... contentType Σ 1..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 SΣ 1..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url Σ 1..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... creation SΣ 1..1 dateTime Date attachment was first created
.... format SΣ 1..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 1..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... period SΣ 0..1 Period Time of service that is being documented
.... facilityType S 1..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 1..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 S 1..1 Reference(Patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required MHD DocumentReference status codes 📦4.2.3-current This IG
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred IHE ValueSet of Format Codes for use with Document Sharing 📦1.4.0 IHE FormatCode Vocabulary v1.4
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

Differential View

This structure is derived from MinimalDocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... type 1..1 CodeableConcept Kind of document (LOINC if possible)
... category 1..1 CodeableConcept Categorization of document
... subject 1..1 Reference(Patient) Who/what is the subject of the document
... securityLabel 1..* CodeableConcept Document security-tags
... content
.... attachment
..... language 1..1 code Human language of the content (BCP-47)
..... creation 1..1 dateTime Date attachment was first created
.... format 1..1 Coding Format/content rules for the document
... context 1..1 BackboneElement Clinical context of document
.... facilityType 1..1 CodeableConcept Kind of facility where patient was seen
.... practiceSetting 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1 Reference(Patient) Patient demographics from source

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* MinimalDocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags 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 ?!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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... masterIdentifier Σ 1..1 UniqueIdIdentifier Master Version Specific Identifier
... Slices for identifier SΣ 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:use
.... identifier:entryUUID SΣ 0..* EntryUUIDIdentifier Other identifiers for the document
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: MHD DocumentReference status codes (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 1..1 CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) 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 SΣ 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 SΣ 1..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content Σ 1..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 Σ 1..1 Attachment Where to access the document
..... 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 Σ 1..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 SΣ 1..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url Σ 1..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 SΣ 1..1 dateTime Date attachment was first created
.... format SΣ 1..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 1..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 0..* Reference(Encounter | EpisodeOfCare) 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start ΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 1..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 1..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 S 1..1 Reference(Patient) Patient demographics from source
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.status Base required MHD DocumentReference status codes 📦4.2.3-current This IG
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred IHE ValueSet of Format Codes for use with Document Sharing 📦1.4.0 IHE FormatCode Vocabulary v1.4
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.5
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​sourcePatientInfo.type Base extensible ResourceType 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
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()

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 11 elements

 

Other representations of profile: CSV, Excel, Schematron