AU eRequesting Implementation Guide
1.0.0-ballot - Ballot Australia flag

AU eRequesting Implementation Guide, published by HL7 Australia. This guide is not an authorized publication; it is the continuous build for version 1.0.0-ballot built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/hl7au/au-fhir-erequesting/ and changes regularly. See the Directory of published versions

Resource Profile: AU eRequesting Clinical Context DocumentReference

Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-clinicalcontext-documentreference Version: 1.0.0-ballot
Standards status: Draft Maturity Level: 1 Computable Name: AUeRequestingClinicalContextDocumentReference

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2024+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for representing Clinical Context using a DocumentReference resource to record, search, and fetch clinical context narrative information that provides an overview of the individual’s current clinical situation assocated with a requested service. Clinical context is intended to describe the broader clinical background or circumstances relating to the request, supporting the service provider in making informed decisions about service delivery. It is based on the DocumentReference and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the DocumentReference when conforming to this profile.

Profile Specific Implementation Guidance

  • Clinical Context is defined as narrative information providing an overview of the individual’s current clinical situation associated with a requested service.
  • This profile constrains DocumentReference.content.attachment to support narrative text only, ensuring consistency with the definition of Clinical Context from AUeReqDI. To support this, the following constraints apply:
    • DocumentReference.content.attachment is mandatory to ensure that Clinical Context is always provided.
    • DocumentReference.content.attachment.contentType is constrained to text/plain, limiting the representation to plain text narrative. This ensures that the content is both human-readable and interoperable across systems without additional rendering or format handling. Other formats such as PDF, DOC, DOCX, or HTML are not permitted.
    • DocumentReference.content.attachment.data must be provided inline using base64 encoding. This ensures that the narrative is included in the resource, avoiding dependencies on external systems or links.
  • These constraints are designed to ensure that Clinical Context is accessible, clearly represented, and consistently exchanged as part of AU eRequesting workflows.

Usages:

You can also check for usages in the FHIR IG Statistics

Changes since version 0.1.0-ballot:

  • New Content

    • Formal Views of Profile Content

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

    This structure is derived from DocumentReference

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... status SO 1..1 code current | superseded | entered-in-error
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... subject SO 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... content SO 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... attachment SO 1..1 Attachment Where to access the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... contentType SO 1..1 code Mime type of the content, with charset etc.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... status ?!SOΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required): The status of the document reference.
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... content SOΣ 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SOΣ 1..1 Attachment Where to access the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... contentType SOΣ 1..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DocumentReference.statusrequiredDocumentReferenceStatus
    http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
    From the FHIR Standard
    DocumentReference.content.attachment.contentTyperequiredFixed Value: text/plain
    http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
    From the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDocumentReferenceA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()
    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    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 Σ 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.
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... 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 SOΣ 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... date Σ 0..1 instant When this document reference was created
    ... author Σ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Who and/or what authored the document
    ... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
    ... custodian 0..1 Reference(Organization) Organization which maintains the document
    ... relatesTo Σ 0..* BackboneElement Relationships to other documents
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code Σ 1..1 code replaces | transforms | signs | appends
    Binding: DocumentRelationshipType (required): The type of relationship between documents.
    .... target Σ 1..1 Reference(DocumentReference) Target of the relationship
    ... description Σ 0..1 string Human-readable description
    ... securityLabel Σ 0..* CodeableConcept Document security-tags
    Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
    ... content SOΣ 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... 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
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... 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 1..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... language Σ 0..1 code Human language of the content (BCP-47)
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding

    Example General: en-AU
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... url Σ 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 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

    PathConformanceValueSet / CodeURI
    DocumentReference.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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.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.attachment.contentTyperequiredFixed Value: text/plain
    http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
    From the FHIR Standard
    DocumentReference.content.attachment.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDocumentReferenceA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    This structure is derived from DocumentReference

    Summary

    Mandatory: 3 elements
    Must-Support: 6 elements
    Fixed: 1 element

    Structures

    This structure refers to these other structures:

    Maturity: 1

    Differential View

    This structure is derived from DocumentReference

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. DocumentReference 0..* DocumentReference A reference to a document
    ... status SO 1..1 code current | superseded | entered-in-error
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... subject SO 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... content SO 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... attachment SO 1..1 Attachment Where to access the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... contentType SO 1..1 code Mime type of the content, with charset etc.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format

    Key Elements View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    ... status ?!SOΣ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required): The status of the document reference.
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... subject SOΣ 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... content SOΣ 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SOΣ 1..1 Attachment Where to access the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... contentType SOΣ 1..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSet / CodeURI
    DocumentReference.statusrequiredDocumentReferenceStatus
    http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
    From the FHIR Standard
    DocumentReference.content.attachment.contentTyperequiredFixed Value: text/plain
    http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
    From the FHIR Standard

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDocumentReferenceA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    Snapshot View

    NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
    .. 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
    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 Σ 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.
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... 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 SOΣ 1..1 Reference(AU Core Patient) Who/what is the subject of the document
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ... date Σ 0..1 instant When this document reference was created
    ... author Σ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Who and/or what authored the document
    ... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
    ... custodian 0..1 Reference(Organization) Organization which maintains the document
    ... relatesTo Σ 0..* BackboneElement Relationships to other documents
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code Σ 1..1 code replaces | transforms | signs | appends
    Binding: DocumentRelationshipType (required): The type of relationship between documents.
    .... target Σ 1..1 Reference(DocumentReference) Target of the relationship
    ... description Σ 0..1 string Human-readable description
    ... securityLabel Σ 0..* CodeableConcept Document security-tags
    Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
    ... content SOΣ 1..* BackboneElement Document referenced
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    .... 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
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... 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 1..1 code Mime type of the content, with charset etc.
    Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
    Fixed Value: text/plain
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... language Σ 0..1 code Human language of the content (BCP-47)
    Binding: CommonLanguages (preferred): A human language.
    Additional BindingsPurpose
    AllLanguages Max Binding

    Example General: en-AU
    ..... data SO 1..1 base64Binary Data inline, base64ed
    ObligationsActor
    SHALL:populate AU eRequesting Placer
    SHALL:handle AU eRequesting Filler
    SHALL:handle AU eRequesting Server
    SHALL:able-to-populate AU eRequesting Server
    SHALL:no-error AU eRequesting Patient
    ..... url Σ 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 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

    PathConformanceValueSet / CodeURI
    DocumentReference.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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.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.attachment.contentTyperequiredFixed Value: text/plain
    http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
    From the FHIR Standard
    DocumentReference.content.attachment.languagepreferredCommonLanguages
    http://hl7.org/fhir/ValueSet/languages
    From the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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

    Constraints

    IdGradePath(s)DetailsRequirements
    dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
    : contained.contained.empty()
    dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
    : contained.meta.security.empty()
    dom-6best practiceDocumentReferenceA resource should have narrative for robust management
    : text.`div`.exists()
    ele-1error**ALL** elementsAll FHIR elements must have a @value or children
    : hasValue() or (children().count() > id.count())
    ext-1error**ALL** extensionsMust have either extensions or value[x], not both
    : extension.exists() != value.exists()

    This structure is derived from DocumentReference

    Summary

    Mandatory: 3 elements
    Must-Support: 6 elements
    Fixed: 1 element

    Structures

    This structure refers to these other structures:

    Maturity: 1

     

    Other representations of profile: CSV, Excel, Schematron

    Notes:

    Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU eRequesting 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 eRequesting interactions is defined here.

    Any search parameter defined in FHIR may be ‘allowed’ by the system unless explicitly marked as “SHALL NOT”.

    Parameter(s) Server Conformance Placer Conformance Filler Conformance Patient Conformance Type(s) Requirements (when used alone or in combination)
    _id SHALL MAY MAY MAY token

    Search Parameters:

    The following search parameters and search parameter combinations are supported. Conformance obligations are detailed in the table above.

    1. _id search parameter

      GET [base]/DocumentReference?_id=[id]

      Example:

      1. GET [base]/DocumentReference?_id=123654

    Implementation Notes: Fetches a bundle with the requested DocumentReference, instead of just the resource itself, and allows for the inclusion of additional search parameters such as _include, _revinclude, or _lastUpdated (how to search by id of the resource)