AU eRequesting Implementation Guide
1.0.0-ci-build - CI Build
AU eRequesting Implementation Guide
1.0.0-ci-build - CI Build
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-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-erequesting/ and changes regularly. See the Directory of published versions
| Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-clinicalcontext-documentreference | Version: 1.0.0-ci-build | |||
| 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. |
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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 associated 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 resource and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the DocumentReference when conforming to this profile.
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.Usages:
You can also check for usages in the FHIR IG Statistics
Changes since version 1.0.0-ballot:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
| 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 | ||||||||||||
| 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): Precise type of clinical document. Required Pattern: At least the following
| ||||||||||||
 id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
 coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7 | |||||||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||||||
 userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||||||
 subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of 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 | 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
| ||||||||||||
| data |
SO | 1..1 | base64Binary | Data inline, base64ed
| ||||||||||||
| 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.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()
|
| 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 |
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.
| ||||||||||||
| 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): Precise type of clinical document. Required Pattern: At least the following
| ||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7 | |||||||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||||||
| 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
| ||||||||||||
| 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
| ||||||||||||
| 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 | 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
| ||||||||||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||||||||||
| data |
SO | 1..1 | base64Binary | Data inline, base64ed
| ||||||||||||
| 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 | |||||||||||||
| 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 v6.5 |
| 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: 4 elements
Must-Support: 7 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Maturity: 1
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||||||||||
 status |
SO | 1..1 | code | current | superseded | entered-in-error
| ||||||||||||
| type |
SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Required Pattern: At least the following
| ||||||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7 | |||||||||||||
| subject |
SO | 1..1 | Reference(AU Core Patient) | Who/what is the subject of the document
| ||||||||||||
| content |
SO | 1..* | BackboneElement | Document referenced
| ||||||||||||
| attachment |
SO | 1..1 | Attachment | Where to access the document
| ||||||||||||
| contentType |
SO | 1..1 | code | Mime type of the content, with charset etc. Fixed Value: text/plain
| ||||||||||||
| data |
SO | 1..1 | base64Binary | Data inline, base64ed
| ||||||||||||
| Documentation for this format | ||||||||||||||||
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 | ||||||||||||
| 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): Precise type of clinical document. Required Pattern: At least the following
| ||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7 | |||||||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||||||
| subject |
SOΣ | 1..1 | Reference(AU Core Patient) | Who/what is the subject of 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 | 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
| ||||||||||||
| data |
SO | 1..1 | base64Binary | Data inline, base64ed
| ||||||||||||
| 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.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()
|
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 |
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.
| ||||||||||||
| 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): Precise type of clinical document. Required Pattern: At least the following
| ||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| coding |
1..* | Coding | Code defined by a terminology system Fixed Value: (Complex) | |||||||||||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||||||||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||||||||||
| system |
1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |||||||||||||
| version |
0..1 | string | Version of the system - if relevant | |||||||||||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7 | |||||||||||||
| display |
0..1 | string | Representation defined by the system | |||||||||||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||||||||||
| text |
0..1 | string | Plain text representation of the concept | |||||||||||||
| 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
| ||||||||||||
| 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
| ||||||||||||
| 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 | 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
| ||||||||||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||||||||||
| data |
SO | 1..1 | base64Binary | Data inline, base64ed
| ||||||||||||
| 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 | |||||||||||||
| 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 v6.5 |
| 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: 4 elements
Must-Support: 7 elements
Fixed: 1 element
Structures
This structure refers to these other structures:
Maturity: 1
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 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 |
The following search parameters and search parameter combinations are supported. Conformance obligations are detailed in the table above.
_id search parameter
GET [base]/DocumentReference?_id=[id]
Example:
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)
IG © 2024 HL7 Australia. Package hl7.fhir.au.ereq#1.0.0-ci-build based on FHIR 4.0.1. Generated 2025-10-20
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