Cross Border Data Exchange IG
1.0.0 - CI Build
Cross Border Data Exchange IG
1.0.0 - CI Build
Cross Border Data Exchange IG, published by IEHR-Workgroup. This guide is not an authorized publication; it is the continuous build for version 1.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/InteropEHRate-project/cross-border-data-exchange/ and changes regularly. See the Directory of published versions
| Official URL: http://interopehrate.eu/fhir/StructureDefinition/DocumentReference-IEHR | Version: 1.0.0 | |||
| Draft as of 2024-04-08 | Computable Name: DocumentReferenceIEHR | |||
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference |
DocumentReference | |||
  Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
 Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR |
 status |
S | 1..1 | code | current | superseded | entered-in-error |
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error | |
| type |
S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) |
| category |
0..* | CodeableConcept | Categorization of document | |
 subject |
S | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document |
| date |
S | 1..1 | instant | When this document reference was created |
| author |
0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | |
| description |
0..1 | string | Human-readable description | |
 content |
S | 1..* | BackboneElement | Document referenced |
  attachment |
1..1 | AttachmentIEHR | Content in a format defined elsewhere | |
 format |
0..1 | Coding | Format/content rules for the document | |
 context |
||||
 encounter |
0..* | Reference(Encounter-IEHR) | Context of the document content | |
| period |
S | 1..1 | PeriodIEHR | Time range defined by start and end date/time |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) |
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject |
SΣ | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document |
| date |
SΣ | 1..1 | instant | When this document reference was created |
| author |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| description |
Σ | 0..1 | string | Human-readable description |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
C | 1..1 | AttachmentIEHR | Content in a format defined elsewhere att-1: If the Attachment has data, it SHALL have a contentType attIEHR-1: At least one of data and url SHALL be present |
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. |
| context |
Σ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| encounter |
0..* | Reference(Encounter-IEHR) | Context of the document content | |
| period |
SC | 1..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard | |
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | |
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| att-1 | error | DocumentReference.content.attachment | If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists() | |
| attIEHR-1 | error | DocumentReference.content.attachment | At least one of data and url SHALL be present : data.exists() or url.exists() | |
| 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() | |
| per-1 | error | DocumentReference.context.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
Σ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document | ||||
| date |
SΣ | 1..1 | instant | When this document reference was created | ||||
| author |
Σ | 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 |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
C | 1..1 | AttachmentIEHR | Content in a format defined elsewhere att-1: If the Attachment has data, it SHALL have a contentType attIEHR-1: At least one of data and url SHALL be present | ||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
0..* | Reference(Encounter-IEHR) | 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 |
SC | 1..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| att-1 | error | DocumentReference.content.attachment | If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists() | |
| attIEHR-1 | error | DocumentReference.content.attachment | At least one of data and url SHALL be present : data.exists() or url.exists() | |
| 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() | |
| per-1 | error | DocumentReference.context.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
This structure is derived from DocumentReference
Summary
Mandatory: 5 elements(1 nested mandatory element)
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
DocumentReference | |||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR |
| status |
S | 1..1 | code | current | superseded | entered-in-error |
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error | |
| type |
S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) |
| category |
0..* | CodeableConcept | Categorization of document | |
| subject |
S | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document |
| date |
S | 1..1 | instant | When this document reference was created |
| author |
0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | |
| description |
0..1 | string | Human-readable description | |
| content |
S | 1..* | BackboneElement | Document referenced |
| attachment |
1..1 | AttachmentIEHR | Content in a format defined elsewhere | |
| format |
0..1 | Coding | Format/content rules for the document | |
| context |
||||
| encounter |
0..* | Reference(Encounter-IEHR) | Context of the document content | |
| period |
S | 1..1 | PeriodIEHR | Time range defined by start and end date/time |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |
| Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. |
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) |
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| subject |
SΣ | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document |
| date |
SΣ | 1..1 | instant | When this document reference was created |
| author |
Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| description |
Σ | 0..1 | string | Human-readable description |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
C | 1..1 | AttachmentIEHR | Content in a format defined elsewhere att-1: If the Attachment has data, it SHALL have a contentType attIEHR-1: At least one of data and url SHALL be present |
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. |
| context |
Σ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| encounter |
0..* | Reference(Encounter-IEHR) | Context of the document content | |
| period |
SC | 1..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | |
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | |
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard | |
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | |
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| att-1 | error | DocumentReference.content.attachment | If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists() | |
| attIEHR-1 | error | DocumentReference.content.attachment | At least one of data and url SHALL be present : data.exists() or url.exists() | |
| 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() | |
| per-1 | error | DocumentReference.context.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| Slices for extension |
0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| Provenance |
S | 1..1 | Reference(Provenance-IEHR) | Extension URL: http://interopehrate.eu/fhir/StructureDefinition/ProvenanceExtension-IEHR | ||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
Σ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (required) | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Patient-IEHR) | Who/what is the subject of the document | ||||
| date |
SΣ | 1..1 | instant | When this document reference was created | ||||
| author |
Σ | 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 |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
C | 1..1 | AttachmentIEHR | Content in a format defined elsewhere att-1: If the Attachment has data, it SHALL have a contentType attIEHR-1: At least one of data and url SHALL be present | ||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
0..* | Reference(Encounter-IEHR) | 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 |
SC | 1..1 | PeriodIEHR | Time range defined by start and end date/time per-1: If present, start SHALL have a lower value than end | ||||
| 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 | ||||||||
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | required | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes|4.0.1from the FHIR Standard | ||||
| DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| att-1 | error | DocumentReference.content.attachment | If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists() | |
| attIEHR-1 | error | DocumentReference.content.attachment | At least one of data and url SHALL be present : data.exists() or url.exists() | |
| 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() | |
| per-1 | error | DocumentReference.context.period | If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end) |
This structure is derived from DocumentReference
Summary
Mandatory: 5 elements(1 nested mandatory element)
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Other representations of profile: CSV, Excel, Schematron