AU Core Implementation Guide
2.0.1-ci-build - CI Build
AU Core Implementation Guide
2.0.1-ci-build - CI Build
AU Core Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 2.0.1-ci-build built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-core/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-documentreference | Version: 2.0.1-ci-build | |||
| Standards status: Trial-use | Maturity Level: 0 | Computable Name: AUCoreDocumentReference | ||
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2022+; Licensed Under Creative Commons No Rights Reserved. |
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This profile sets minimum expectations for a DocumentReference resource to record, search, and fetch documents associated with a patient. It is based on the DocumentReference resource and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the DocumentReference resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.
See Comparison with other national and international IGs for a comparison between AU Core profiles and profiles in other implementation guides.
The following are supported usage scenarios for this profile:
No guidance defined.
Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 2.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
  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 |
SOΣ | 0..* | Identifier | Other identifiers for the document
| ||||||||||
| status |
?!SOΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
| ||||||||||
| type |
SOΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred)
| ||||||||||
| category |
SOΣ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
| ||||||||||
 subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||
| date |
SOΣ | 0..1 | instant | When this document reference was created
| ||||||||||
| author |
SOΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization | Device) | Who and/or what authored the document
| ||||||||||
 content |
SOΣ | 1..* | BackboneElement | Document referenced
| ||||||||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||||
 attachment |
SOΣ | 1..1 | Attachment | Where to access the document
| ||||||||||
 contentType |
SOΣ | 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 |
SO | 0..1 | base64Binary | Data inline, base64ed
| ||||||||||
 url |
SOΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
| ||||||||||
| context |
SOΣ | 0..1 | BackboneElement | Clinical context of document
| ||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||||
| period |
SOΣ | 0..1 | Period | Time of service that is being documented
| ||||||||||
| Documentation for this format | ||||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| 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.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| 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 DocumentReference
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | preferred | Document Type Value Set | 📦4.0.1 | FHIR Std. |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 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 | |||||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||||||||
| identifier |
SOΣ | 0..* | Identifier | Other identifiers for the document
| ||||||||||
| status |
?!SOΣ | 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 |
SOΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred)
| ||||||||||
| category |
SOΣ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||
| date |
SOΣ | 0..1 | instant | When this document reference was created
| ||||||||||
| author |
SOΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization | Device) | 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 |
SOΣ | 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 |
SOΣ | 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 |
SOΣ | 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
| ||||||||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||||||||
| data |
SO | 0..1 | base64Binary | Data inline, base64ed
| ||||||||||
| url |
SOΣ | 0..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 |
Σ | 0..1 | dateTime | Date attachment was first created | ||||||||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||||||||
| context |
SOΣ | 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 |
SOΣ | 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 | |||||||||||
| Documentation for this format | ||||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| 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 | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.2 |
| 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. |
| 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 DocumentReference
Summary
Mandatory: 2 elements
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Maturity: 0
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
SOΣ | 0..* | Identifier | Other identifiers for the document
| ||||||||||
| status |
?!SOΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
| ||||||||||
| type |
SOΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred)
| ||||||||||
| category |
SOΣ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||
| date |
SOΣ | 0..1 | instant | When this document reference was created
| ||||||||||
| author |
SOΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization | Device) | Who and/or what authored the document
| ||||||||||
| content |
SOΣ | 1..* | BackboneElement | Document referenced
| ||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||||
| attachment |
SOΣ | 1..1 | Attachment | Where to access the document
| ||||||||||
| contentType |
SOΣ | 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 |
SO | 0..1 | base64Binary | Data inline, base64ed
| ||||||||||
| url |
SOΣ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
| ||||||||||
| context |
SOΣ | 0..1 | BackboneElement | Clinical context of document
| ||||||||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||||||||
| period |
SOΣ | 0..1 | Period | Time of service that is being documented
| ||||||||||
| Documentation for this format | ||||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| 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.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| 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 DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||||||||
 identifier |
SO | 0..* | Identifier | Other identifiers for the document
| ||||||||||
| status |
SO | 1..1 | code | current | superseded | entered-in-error
| ||||||||||
| type |
SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred)
| ||||||||||
| category |
SO | 0..* | CodeableConcept | Categorization of document
| ||||||||||
| subject |
SO | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||
| date |
SO | 0..1 | instant | When this document reference was created
| ||||||||||
| author |
SO | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization | Device) | Who and/or what authored the document
| ||||||||||
| content |
SO | 1..* | BackboneElement | Document referenced
| ||||||||||
| attachment |
SO | 1..1 | Attachment | Where to access the document
| ||||||||||
| contentType |
SO | 0..1 | code | Mime type of the content, with charset etc.
| ||||||||||
| data |
SO | 0..1 | base64Binary | Data inline, base64ed
| ||||||||||
| url |
SO | 0..1 | url | Uri where the data can be found
| ||||||||||
| context |
SO | 0..1 | BackboneElement | Clinical context of document
| ||||||||||
| period |
SO | 0..1 | Period | Time of service that is being documented
| ||||||||||
| Documentation for this format | ||||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | preferred | Document Type Value Set | 📦4.0.1 | FHIR Std. |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 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 | |||||||||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored | ||||||||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||||||||
| identifier |
SOΣ | 0..* | Identifier | Other identifiers for the document
| ||||||||||
| status |
?!SOΣ | 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 |
SOΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred)
| ||||||||||
| category |
SOΣ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
| ||||||||||
| subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||
| date |
SOΣ | 0..1 | instant | When this document reference was created
| ||||||||||
| author |
SOΣ | 0..* | Reference(AU Core Practitioner | AU Core PractitionerRole | AU Core Patient | AU Core RelatedPerson | AU Core Organization | Device) | 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 |
SOΣ | 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 |
SOΣ | 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 |
SOΣ | 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
| ||||||||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||||||||
| data |
SO | 0..1 | base64Binary | Data inline, base64ed
| ||||||||||
| url |
SOΣ | 0..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 |
Σ | 0..1 | dateTime | Date attachment was first created | ||||||||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||||||||
| context |
SOΣ | 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 |
SOΣ | 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 | |||||||||||
| Documentation for this format | ||||||||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| 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 | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.2 |
| 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. |
| 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 DocumentReference
Summary
Mandatory: 2 elements
Must-Support: 14 elements
Structures
This structure refers to these other structures:
Maturity: 0
Other representations of profile: CSV, Excel, Schematron
Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU Core CapabilityStatements for a complete list of supported RESTful interactions for this IG.
FHIR search operations are described here and the syntax used to describe AU Core interactions is defined here.
Any search parameter defined in FHIR may be 'allowed' by the system unless explicitly marked as "SHALL NOT". A few items are marked as MAY in this implementation guide to highlight their potential relevance.
| Parameter(s) | Conformance | Type(s) | Requirements (when used alone or in combination) |
|---|---|---|---|
| patient | SHALL | reference |
The requester SHALL provide at least an id value and MAY provide both the Type and id values. The responder SHALL support both. The requester SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. The responder SHOULD support chained search patient.identifier using IHI, Medicare Number, and DVA Number identifiers as defined in the AU Core Patient profile. |
| patient+type | SHALL | reference+token |
|
| patient+author | SHOULD | reference+reference |
|
| patient+type+period | SHOULD | reference+token+date |
|
| patient+type+date | SHOULD | reference+token+date |
|
| author | MAY | reference |
|
| date | MAY | date |
A requester SHALL provide a value precise to the second + time offset. A responder SHALL support a value precise to the second + time offset. The requester SHALL support these search comparators gt, lt, ge, le. The responder SHALL support these search comparators gt, lt, ge, le.The requester SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le. The responder SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le. |
| period | MAY | date |
A requester SHALL provide a value precise to the second + time offset. A responder SHALL support a value precise to the second + time offset. The requester SHALL support these search comparators gt, lt, ge, le. The responder SHALL support these search comparators gt, lt, ge, le.The requester SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le. The responder SHOULD support multipleAnd, and if multipleAnd is supported, SHALL support the search comparators gt, lt, ge, le. |
| type | MAY | token |
The requester SHALL provide at least a code value and MAY provide both the system and code values. The responder SHALL support both. |
The following search parameters and search parameter combinations SHALL be supported:
patient search parameter:
patient.identifier (e.g. patient.identifier=[system|][code])GET [base]/DocumentReference?patient={Type/}[id] or optionally GET [base]/DocumentReference?patient.identifier=[system|][code]
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient (how to search by reference and how to search by token)
patient and type search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type (how to search by reference and how to search by token)
The following search parameters and search parameter combinations SHOULD be supported:
patient and author search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])GET [base]/DocumentReference?patient={Type/}[id]&author={Type/}[id]
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and author (how to search by reference)
patient and type and date search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])date comparators: gt,lt,ge,ledate (e.g.date=[date]&date=[date]&...), and if multipleAnd is supported, SHALL support the search comparators gt,lt,ge,leGET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and date (how to search by reference and how to search by token and how to search by date)
patient and type and period search parameters:
patient.identifier (e.g. patient.identifier=[system|][code])period comparators: gt,lt,ge,leperiod (e.g.period=[date]&period=[date]&...), and if multipleAnd is supported, SHALL support the search comparators gt,lt,ge,leGET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}
Example:
Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and period (how to search by reference and how to search by token and how to search by date)
IG © 2022+ HL7 Australia. Package hl7.fhir.au.core#2.0.1-ci-build based on FHIR 4.0.1. Generated 2026-07-01
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