MyHealtheVet PHR FHIR API
0.3.9-current - ci-build United States of America flag

MyHealtheVet PHR FHIR API, published by VA Digital Services. This guide is not an authorized publication; it is the continuous build for version 0.3.9-current built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/department-of-veterans-affairs/mhv-fhir-phr-mapping/ and changes regularly. See the Directory of published versions

Resource Profile: VA MHV All DocumentReference

Official URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/VA.MHV.PHR.documentReference Version: 0.3.9-current
Standards status: Trial-use Maturity Level: 4 Computable Name: MHVdocumentReference

A profile on the DocumentReference resource that covers all uses of FHIR DocumentReference in the MyHealtheVet FHIR API. This includes Physician Notes, Discharge Summary, and ECG/EKG reports.

  • based on US-Core documentReference Resource profile for clinical notes
  • category will have clinical-note
  • type indicates the specific type of document
  • subject is a reference to this patient
  • status is current or entered-in-error
  • identifier will hold the record identifier from Vista
    • may hold case number
  • date the report date/time (aka. Reference Date/Time)
  • author the report author
    • In a Discharge Summary the author would have historically been known as the Discharge Physician
    • In a Discharge Summary historically the Admitting Physician is harvested from the content body from ATTENDING:
  • authenticator may hold the approver of the report
  • authenticator.extension[when] may hold the date/time approved
  • context.period may hold the admit date/time and discharge date/time
  • context.related may hold the location
  • context.encounter may hold the encounter identifier
  • content.attachment.title may be a local title for the report
  • content.attachment.creation may be the report timestamp
  • content.attachment.contentType will be text/plain
  • content.attachment.data the report text in base64 encoding
    • Note that Cerner uses content.attachment.url that points at a FHIR Binary holding the text
  • no other elements are populated

To search for clinical-notes, use the category parameter with clinical-note code (i.e., &category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note). Should search for entries that do not have status=entered-in-error (might also work to look for only current) (i.e., &status:not=entered-in-error)

GET {path}/DocumentReference?patient={patient}&status:not=entered-in-error&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category clinical-note

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile A reference to a document
... masterIdentifier 0..0
... status 1..1 code May indicate entered-in-error
... docStatus 0..0
... type
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
... author 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... Slices for extension Content/Rules for all slices
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
... custodian 0..0
... relatesTo 0..0
... description 0..0
... securityLabel 0..0
... content 1..1 BackboneElement Document referenced
.... attachment
..... language 0..0
..... url 0..0
..... size 0..0
..... hash 0..0
..... title S 0..1 string Label to display in place of the data
..... creation S 0..1 dateTime Date attachment was first created
.... format 0..0
... context
.... event 0..0
.... facilityType 0..0
.... practiceSetting 0..0
.... sourcePatientInfo 0..0
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} Related identifiers or resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile 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 SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code May indicate entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO Σ 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ 0..* CodeableConcept Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... Slices for extension Content/Rules for all slices
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
... content SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ 0..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
..... data SC 0..1 base64Binary Data inline, base64ed
..... title SΣ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ 0..1 dateTime Date attachment was first created
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile 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
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code May indicate entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO Σ 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ 0..* CodeableConcept Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
.... 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
... content SΣ 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 SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... 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 SΣ 0..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
..... data SC 0..1 base64Binary Data inline, base64ed
..... title SΣ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ 0..1 dateTime Date attachment was first created
... context SΣ 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 S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} 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
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.authenticator.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.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard

Differential View

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile A reference to a document
... masterIdentifier 0..0
... status 1..1 code May indicate entered-in-error
... docStatus 0..0
... type
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... system 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
... author 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... Slices for extension Content/Rules for all slices
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
... custodian 0..0
... relatesTo 0..0
... description 0..0
... securityLabel 0..0
... content 1..1 BackboneElement Document referenced
.... attachment
..... language 0..0
..... url 0..0
..... size 0..0
..... hash 0..0
..... title S 0..1 string Label to display in place of the data
..... creation S 0..1 dateTime Date attachment was first created
.... format 0..0
... context
.... event 0..0
.... facilityType 0..0
.... practiceSetting 0..0
.... sourcePatientInfo 0..0
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} Related identifiers or resources

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile 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 SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code May indicate entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO Σ 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ 0..* CodeableConcept Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... Slices for extension Content/Rules for all slices
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
... content SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ 0..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
..... data SC 0..1 base64Binary Data inline, base64ed
..... title SΣ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ 0..1 dateTime Date attachment was first created
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile 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
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code May indicate entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:system
..... coding:LO Σ 1..1 Coding Code defined by a terminology system
Binding: Known DocumentReference types (required)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ 0..* CodeableConcept Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) {c} Who and/or what authored the document
... authenticator S 0..1 Reference(VA MHV PHR Practitioner | Practitioner) {c} Who/what authenticated the document
.... id 0..1 string Unique id for inter-element referencing
.... Slices for extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... when S 0..1 dateTime When the authentication happened
URL: https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/StructureDefinition/noteAuthenticatedWhen
.... 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
... content SΣ 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 SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... 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 SΣ 0..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
..... data SC 0..1 base64Binary Data inline, base64ed
..... title SΣ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation SΣ 0..1 dateTime Date attachment was first created
... context SΣ 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 S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented
.... related S 0..* Reference(VA MHV PHR Location | Location) {c} 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
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
DocumentReference.type.coding:LOrequiredDocumentReferenceTypeVS
https://department-of-veterans-affairs.github.io/mhv-fhir-phr-mapping/ValueSet/DocumentReferenceTypeVS
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
DocumentReference.authenticator.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.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard

 

Other representations of profile: CSV, Excel, Schematron

Notes:

For mapping details see notes, ecg, and imaging notes.