Virtually Healthcare HL7 FHIR R4 Implementation Guide
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Virtually Healthcare HL7 FHIR R4 Implementation Guide, published by Virtually Healthcare. This guide is not an authorized publication; it is the continuous build for version 0.1.0-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/Virtually-Healthcare/HL7-FHIR-Implementation-Guide/ and changes regularly. See the Directory of published versions

Resource Profile: DocumentReference

Official URL: https://fhir.virtually.healthcare/StructureDefinition/DocumentReference Version: 0.1.0-current
Draft as of 2024-11-20 Computable Name: DocumentReference

Merge of IHE Europe XDS, UKCore DocumentReference and includes elements from HL7 International Patient Access

Mappings and Model

This is based on converting IHE Europe Document Metadata (which contains references to NHS England terminology), to HL7 FHIR following DocumentReference - XDS metadata equivalent

For HL7 v2 MDM T02, see HL7 v2 MDM T02 Mapping

IHE XDS Document Entry IHE MHD FHIR DocumentReference Use Description Notes and NHS Data Dictionary Link
uniqueId masterIdentifier Primary Query The globally unique identifier assigned by the document creator to this document. This unique identifier may be used in the body of other documents to reference this document. The structure and format of this Id is consistent with the document content Interoperability Specification, in particular with the formatCode attribute. Has a single value.  
entryUUID identifier Technical This globally unique identifier is primarily intended foruse as a document registry management identifier. It is not meant to be an external reference (outside of the Document Registry) for documents (e.g., in links within other documents)  
availabilityStatus status Primary Query    
type type Secondary Filtering The code specifying the precise type of document from the user perspective (e.g. Pulmonary History and Physical, Discharge Summary, Ultrasound Report).  
class category Primary Query The code specifying the high-level use classification of the document type (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow). The code specifying the particular kind of document. Shall have a single value. Coded with a coarse level of granularity.  
patientId subject Primary Query The patientId represents the subject of care of the document. It contains the Health ID with its two parts: Authority Domain Id (OID/System Uri enforced by the Registry) An Id in the above domain issued by the PDQ Supplier Actor (NHS England PAS) HL7 v2 CX - Extended Composite ID (HL7 FHIR Identifier) NHS NUMBER
author author Secondary Filtering The humans and/or machines that authored the document. HL7 v2 XCN - Extended Composite ID Number And Name (HL7 FHIR Identifier)
ORGANISATION CODE
CONSULTANT CODE
GENERAL MEDICAL PRACTITIONER PPD CODE
creationTime content.attachment.date Secondary Filtering    
title content.attachment.title Secondary Filtering Represents the title of the document  
comments description Secondary Filtering Comments associated with the Document.  
confidentialityCode securityLabel Primary Query The code specifying the level of confidentiality of the document. Has one or more values.  
eventCodeList context.event Primary Query This list of codes represents the main clinical “key words” for queries specific to certain document content (e.g. test panel code for laboratory results).The value chosen shall not conflict with the values selected in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This value list may have zero or more values.  
serviceStartTime and serviceStopTime context.period Primary Query Represents the start and stop time the service being documented took place (clinically significant, but not necessarily when the document was produced or approved).  
practiceSettingCode context.practiceSetting Primary Query This code represents the type of organizational setting of the clinical encounter during which the documented act occurred. The code specifying the clinical specialty where the act that resulted in the document was performed (e.g., Intensive care, Laboratory, Radiology). Coarse level of granularity. Has a single value MAIN SPECIALTY CODE
healthcareFacilityTypeCode context.facilityType Primary Query This code represents the type of organization where the clinical encounter during which the documented act occurred. The value chosen in the value set needs to avoid conflict with the value used in the typeCode, as such a conflict would create an ambiguous situation. Has a single value. ACTIVITY LOCATION TYPE CODE
sourcePatientInfo and sourcePatientId context.sourcePatientInfo   The sourcePatientId represents the subject of care medical record Identifier (e.g., Patient Id) in the local patientIdentifier Domain of the Document Source. If used, it contains two parts:Authority Domain Id (System Uri/OID) and an Id in the local domain (e.g., Patient Id). It is only intended as an audit/checking mechanism and has occasional use for Document Consumer Actors. HL7 v2 CX - Extended Composite ID (HL7 FHIR Identifier) Medical Record Number
referenceIdList context.related Primary Query This list contains zero or more Identifiers. These Identifiers may be internal or external identifiers, E.g., Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDW Workflow, Instance Identifiers, etc. HL7 v2 EI - Entity Identifier (HL7 FHIR Identifier) RADIOLOGICAL ACCESSION NUMBER
mimeType content.attachment.contentType Technical MIME type of the document in the Repository. Shall have a single value  
URI content.attachment.uri Technical The URI for the document  
languageCode content.attachment.language   Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066. Has a single value.  
formatCode content.format Technical Code globally uniquely specifying the format of the document. Along with the typeCode, it provides sufficient information to allow any potential Document Consumer to know if it will be able to process/display the document by identifying an encoding, structure and template  
hash content.attachment.hash Technical Hash key of the document itself. This value is computed by the Document Repository and used by the Document Registry for detecting tampering or the improper resubmission of documents .Has a single value  
size content.attachment.size Technical Size in bytes of the byte stream of the document  
legalAuthenticator authenticator   Represents a participant within an authorInstitution who has legally authenticated or attested the document. Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator. This attribute may be absent if not applicable. If present, shall have a single value  
Associations relatesTo   Relationships to other documents  
Associations type relatesTo.code      
Associations reference relatesTo.target      
objectType     The type of DocumentEntry (e.g. On-Demand DocumentEntry)  

Links to other countries Document Metadata definitions:

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... subject 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumbers An identifier intended for computation
... author 0..* Reference(Organization | Practitioner) Who and/or what authored the document
.... identifier 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... subject Σ 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumbers An identifier intended for computation
... author Σ 0..* Reference(Organization | Practitioner) Who and/or what authored the document
.... identifier 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation
... content Σ 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... status ?!Σ 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 Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ 1..1 Reference(Patient) Who/what is the subject of 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
.... 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 0..1 NHSNumbers An identifier intended for computation
.... display Σ 0..1 string Text alternative for the resource
... date Σ 0..1 instant When this document reference was created
... author Σ 0..* Reference(Organization | Practitioner) Who and/or what authored 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
.... 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 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation
.... display Σ 0..1 string Text alternative for the resource
... 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 Σ 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
.... 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 | 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 Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... subject 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumbers An identifier intended for computation
... author 0..* Reference(Organization | Practitioner) Who and/or what authored the document
.... identifier 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... status ?!Σ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... subject Σ 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumbers An identifier intended for computation
... author Σ 0..* Reference(Organization | Practitioner) Who and/or what authored the document
.... identifier 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation
... content Σ 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

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier S 1..* CommonResourceIdentifiers An identifier intended for computation
... status ?!Σ 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 Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ 0..* CodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ 1..1 Reference(Patient) Who/what is the subject of 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
.... 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 0..1 NHSNumbers An identifier intended for computation
.... display Σ 0..1 string Text alternative for the resource
... date Σ 0..1 instant When this document reference was created
... author Σ 0..* Reference(Organization | Practitioner) Who and/or what authored 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
.... 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 0..1 ProfessionalLicense, StaffEnterpriseNumber An identifier intended for computation
.... display Σ 0..1 string Text alternative for the resource
... 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 Σ 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
.... 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 | 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 Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typepreferredDocumentTypeValueSet
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron