Healthy Route Implementation Guide, published by Savannah Informatics. This guide is not an authorized publication; it is the continuous build for version 0.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/savannahghi/healthy-route-ig/ and changes regularly. See the Directory of published versions
Resource Profile: Healthy Route Consent Evidence
| Official URL: https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-consent-evidence | Version: 0.1.0 | |||
| Draft as of 2026-09-04 | Computable Name: HRConsentEvidence | |||
The photographed page a participant signed, referenced by the consent it evidences.
Holds the signed paper in retrievable form. A monitor asked to verify that a participant consented before a given procedure needs the page itself, and retrieving it from a site file in another country is not a practical answer during a remote monitoring visit.
Usages:
- Refer to this Profile: Healthy Route Consent
You can also check for usages in the FHIR IG Statistics
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DocumentReference |
C | 0..* | HRDocumentReference | A reference to a document Constraints: docRef-1, docRef-2 |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| contained |
0..* | Resource | Contained, inline Resources | |
  Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |
   extension:tenant |
S | 1..1 | Identifier | Owning site tenant URL: https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-tenant |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
SΣ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document. |
 type |
SΣ | 0..1 | CodeableConcept | Document type Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document. |
 subject |
SΣ | 1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document |
| context |
C | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Context of the document content |
| date |
SΣ | 1..1 | instant | When the document was registered |
| author |
SΣ | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page |
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
 mode |
1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document. | |
| custodian |
S | 1..1 | Reference(Healthy Route Organization) | Organisation holding the original |
| relatesTo |
SΣ | 0..* | BackboneElement | The page this one replaces |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 1..1 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. |
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship |
 Slices for securityLabel |
SΣ | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. |
 securityLabel:confidentiality |
SΣ | 1..1 | CodeableConcept | Restricted Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| 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 | |
 content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| contentType |
SΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png |
| url |
SΣ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| hash |
SΣ | 0..1 | base64Binary | SHA-1 hash of the file |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel:confidentiality | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from HRDocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | HRDocumentReference | A reference to a document | |
 status |
1..1 | code | current | superseded | entered-in-error | |
| docStatus |
S | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown |
| type |
S | 0..1 | CodeableConcept | Document type |
| subject |
1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document | |
| author |
S | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page |
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy |
| relatesTo |
S | 0..* | BackboneElement | The page this one replaces |
| code |
1..1 | CodeableConcept | The relationship type with another document | |
| Slices for securityLabel |
S | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system |
| securityLabel:confidentiality |
S | 1..1 | CodeableConcept | Restricted 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
C | 0..* | HRDocumentReference | A reference to a document Constraints: docRef-1, docRef-2 | ||||
| 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: AllLanguages (required): IETF language tag for 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 | |||||
| Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:tenant |
S | 1..1 | Identifier | Owning site tenant URL: https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-tenant | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifiers for the document | ||||
| version |
Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the DocumentReference | ||||
| basedOn |
0..* | Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription) | Procedure that caused this media to be created | |||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
SΣ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document. | ||||
| modality |
Σ | 0..* | CodeableConcept | Imaging modality used Binding: Modality  (extensible): Type of acquired data in the instance. | ||||
| type |
SΣ | 0..1 | CodeableConcept | Document type Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document | ||||
| context |
C | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Context of the document content | ||||
| event |
0..* | CodeableReference() | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| bodySite |
Σ | 0..* | CodeableReference(BodyStructure) | Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts | ||||
| facilityType |
C | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
C | 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). | ||||
| period |
Σ | 0..1 | Period | Time of service that is being documented | ||||
| date |
SΣ | 1..1 | instant | When the document was registered | ||||
| author |
SΣ | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page | ||||
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy | ||||
| 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 | ||||
| mode |
1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document. | |||||
| time |
0..1 | dateTime | When the document was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the document | |||||
| custodian |
S | 1..1 | Reference(Healthy Route Organization) | Organisation holding the original | ||||
| relatesTo |
SΣ | 0..* | BackboneElement | The page this one replaces | ||||
| 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 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | markdown | Human-readable description | ||||
| Slices for securityLabel |
SΣ | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| securityLabel:confidentiality |
SΣ | 1..1 | CodeableConcept | Restricted Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |||||
| 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 | |||||
| content |
SΣ | 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 |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | id | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language.
Example General: en-AU | ||||
| url |
SΣ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | integer64 | Number of bytes of content (if url provided) | ||||
| hash |
SΣ | 0..1 | base64Binary | SHA-1 hash of the file | ||||
| 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 | ||||
| height |
0..1 | positiveInt | Height of the image in pixels (photo/video) | |||||
| width |
0..1 | positiveInt | Width of the image in pixels (photo/video) | |||||
| frames |
0..1 | positiveInt | Number of frames if > 1 (photo) | |||||
| duration |
0..1 | decimal | Length in seconds (audio / video) | |||||
| pages |
0..1 | positiveInt | Number of printed pages | |||||
| profile |
Σ | 0..* | BackboneElement | Content profile rules for the 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 | ||||
 value[x] |
Σ | 1..1 | Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes. | |||||
| valueCoding |
Coding | |||||||
| valueUri |
uri | |||||||
| valueCanonical |
canonical(Any) | |||||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.modality | Base | extensible |
Modality
|
⏿2025.3.20250714 | tx.fhir.org |
| DocumentReference.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.3 |
| DocumentReference.bodySite | Base | example | SNOMED CT Body Structures | 📍5.0.0 | FHIR Std. |
| DocumentReference.facilityType | Base | example | Facility Type Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.practiceSetting | Base | example | Practice Setting Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel:confidentiality | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.profile.value[x] | Base | preferred | HL7 ValueSet of Format Codes for use with Document Sharing | 📦2.1.0 | THO v7.3 |
Constraints
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from HRDocumentReference
Summary
Mandatory: 3 elements
Must-Support: 7 elements
Structures
This structure refers to these other structures:
- Healthy Route Practitioner (https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-practitioner)
- Healthy Route Organization (https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-organization)
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of DocumentReference.securityLabel
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
C | 0..* | HRDocumentReference | A reference to a document Constraints: docRef-1, docRef-2 |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| contained |
0..* | Resource | Contained, inline Resources | |
| Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |
| extension:tenant |
S | 1..1 | Identifier | Owning site tenant URL: https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-tenant |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| docStatus |
SΣ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document. |
| type |
SΣ | 0..1 | CodeableConcept | Document type Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document. |
| subject |
SΣ | 1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document |
| context |
C | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Context of the document content |
| date |
SΣ | 1..1 | instant | When the document was registered |
| author |
SΣ | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page |
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| mode |
1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document. | |
| custodian |
S | 1..1 | Reference(Healthy Route Organization) | Organisation holding the original |
| relatesTo |
SΣ | 0..* | BackboneElement | The page this one replaces |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| code |
Σ | 1..1 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. |
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship |
| Slices for securityLabel |
SΣ | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. |
| securityLabel:confidentiality |
SΣ | 1..1 | CodeableConcept | Restricted Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| version |
0..1 | string | Version of the system - if relevant | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| 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 | |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| contentType |
SΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png |
| url |
SΣ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| hash |
SΣ | 0..1 | base64Binary | SHA-1 hash of the file |
| Documentation for this format | ||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel:confidentiality | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
Constraints
| Id | Grade | Path(s) | Description | Expression |
Differential View
This structure is derived from HRDocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | HRDocumentReference | A reference to a document | |
| status |
1..1 | code | current | superseded | entered-in-error | |
| docStatus |
S | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown |
| type |
S | 0..1 | CodeableConcept | Document type |
| subject |
1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document | |
| author |
S | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page |
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy |
| relatesTo |
S | 0..* | BackboneElement | The page this one replaces |
| code |
1..1 | CodeableConcept | The relationship type with another document | |
| Slices for securityLabel |
S | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system |
| securityLabel:confidentiality |
S | 1..1 | CodeableConcept | Restricted 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
C | 0..* | HRDocumentReference | A reference to a document Constraints: docRef-1, docRef-2 | ||||
| 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: AllLanguages (required): IETF language tag for 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 | |||||
| Slices for extension |
1..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| extension:tenant |
S | 1..1 | Identifier | Owning site tenant URL: https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-tenant | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored | ||||
| identifier |
Σ | 0..* | Identifier | Business identifiers for the document | ||||
| version |
Σ | 0..1 | string | An explicitly assigned identifer of a variation of the content in the DocumentReference | ||||
| basedOn |
0..* | Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription) | Procedure that caused this media to be created | |||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
SΣ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document. | ||||
| modality |
Σ | 0..* | CodeableConcept | Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance. | ||||
| type |
SΣ | 0..1 | CodeableConcept | Document type Binding: FHIRDocumentTypeCodes (preferred): Precise type of clinical document. | ||||
| category |
Σ | 0..* | CodeableConcept | Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level. | ||||
| subject |
SΣ | 1..1 | Reference(Healthy Route Patient) | Who/what is the subject of the document | ||||
| context |
C | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Context of the document content | ||||
| event |
0..* | CodeableReference() | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| bodySite |
Σ | 0..* | CodeableReference(BodyStructure) | Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts | ||||
| facilityType |
C | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
| practiceSetting |
C | 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). | ||||
| period |
Σ | 0..1 | Period | Time of service that is being documented | ||||
| date |
SΣ | 1..1 | instant | When the document was registered | ||||
| author |
SΣ | 0..* | Reference(Healthy Route Practitioner | Healthy Route Organization) | Who captured the page | ||||
| attester |
S | 0..* | BackboneElement | Who attested the accuracy of the copy | ||||
| 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 | ||||
| mode |
1..1 | CodeableConcept | personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document. | |||||
| time |
0..1 | dateTime | When the document was attested | |||||
| party |
0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the document | |||||
| custodian |
S | 1..1 | Reference(Healthy Route Organization) | Organisation holding the original | ||||
| relatesTo |
SΣ | 0..* | BackboneElement | The page this one replaces | ||||
| 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 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | markdown | Human-readable description | ||||
| Slices for securityLabel |
SΣ | 1..* | CodeableConcept | Document security-tags Slice: Unordered, Open by value:coding.system Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| securityLabel:confidentiality |
SΣ | 1..1 | CodeableConcept | Restricted Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. 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://terminology.hl7.org/CodeSystem/v3-Confidentiality | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
1..1 | code | Symbol in syntax defined by the system Fixed Value: R | |||||
| 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 | |||||
| content |
SΣ | 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 |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | id | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
SΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
Σ | 0..1 | code | Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language.
Example General: en-AU | ||||
| url |
SΣ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | integer64 | Number of bytes of content (if url provided) | ||||
| hash |
SΣ | 0..1 | base64Binary | SHA-1 hash of the file | ||||
| 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 | ||||
| height |
0..1 | positiveInt | Height of the image in pixels (photo/video) | |||||
| width |
0..1 | positiveInt | Width of the image in pixels (photo/video) | |||||
| frames |
0..1 | positiveInt | Number of frames if > 1 (photo) | |||||
| duration |
0..1 | decimal | Length in seconds (audio / video) | |||||
| pages |
0..1 | positiveInt | Number of printed pages | |||||
| profile |
Σ | 0..* | BackboneElement | Content profile rules for the 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 | ||||
| value[x] |
Σ | 1..1 | Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes. | |||||
| valueCoding |
Coding | |||||||
| valueUri |
uri | |||||||
| valueCanonical |
canonical(Any) | |||||||
| Documentation for this format | ||||||||
Terminology Bindings
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.modality | Base | extensible |
Modality
|
⏿2025.3.20250714 | tx.fhir.org |
| DocumentReference.type | Base | preferred | FHIR Document Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.3 |
| DocumentReference.bodySite | Base | example | SNOMED CT Body Structures | 📍5.0.0 | FHIR Std. |
| DocumentReference.facilityType | Base | example | Facility Type Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.practiceSetting | Base | example | Practice Setting Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel:confidentiality | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.profile.value[x] | Base | preferred | HL7 ValueSet of Format Codes for use with Document Sharing | 📦2.1.0 | THO v7.3 |
Constraints
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from HRDocumentReference
Summary
Mandatory: 3 elements
Must-Support: 7 elements
Structures
This structure refers to these other structures:
- Healthy Route Practitioner (https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-practitioner)
- Healthy Route Organization (https://fhir.savannahghi.org/ig/healthy-route/StructureDefinition/hr-organization)
Slices
This structure defines the following Slices:
- The element 1 is sliced based on the value of DocumentReference.securityLabel
Other representations of profile: CSV, Excel, Schematron