SIL HIE Implementation Guide
0.1.0 - sil-hie-active

SIL HIE Implementation Guide, published by Kathurima Kimathi. 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/hie-fhir-ig-profile/ and changes regularly. See the Directory of published versions

Resource Profile: HIE DocumentReference

Official URL: https://nshr.dha.go.ke/fhir/StructureDefinition/hie-documentreference Version: 0.1.0
Active as of 2025-11-25 Computable Name: HIEDocumentReference

R4B DocumentReference constrained for HIE exchange. Requires strong typing, subject linkage, and well-formed attachments.

Usages:

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.

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
... identifier SΣ 1..* Identifier Other identifiers for the document
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... docStatus Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ 1..1 HIECodeableConcept Kind of document (LOINC if possible)
Binding: FHIRDocumentTypeCodes (extensible)
... category SΣ 1..* HIECodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date SΣ 1..1 instant When this document reference was created
... author SΣ 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE Organization) Organization which maintains the document
... securityLabel Σ 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... 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 SΣ 1..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049)
Example General: text/plain; charset=UTF-8, image/png

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.3.0 FHIR Std.

Constraints

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.exists() and ('#'+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(uri) = '#').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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 1..* Identifier Other identifiers for the document
.... use 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system 1..1 uri The namespace for the identifier value
.... value S 1..1 string The value that is unique
.... assigner S 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status S 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... category S 1..* HIECodeableConcept Categorization of document
... subject S 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date S 1..1 instant When this document reference was created
... author S 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE Organization) Organization which maintains the document
... relatesTo
.... target 1..1 HIEReference(HIE DocumentReference) Target of the relationship
... securityLabel 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... content S 1..* BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
..... contentType S 1..1 code Mime type of the content, with charset etc.
... context
.... encounter 1..1 HIEReference(HIE Encounter | HIE EpisodeOfCare) Context of the document content
.... event 0..* HIECodeableConcept Main clinical acts documented
.... facilityType 0..1 HIECodeableConcept Kind of facility where patient was seen
.... practiceSetting 0..1 HIECodeableConcept Additional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1 HIEReference(HIE Patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.
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
... 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
Constraints: dom-r4b
... 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 SΣ 1..* Identifier Other identifiers for 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
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ 1..1 HIECodeableConcept Kind of document (LOINC if possible)
Binding: FHIRDocumentTypeCodes (extensible)
... category SΣ 1..* HIECodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date SΣ 1..1 instant When this document reference was created
... author SΣ 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE 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 HIEReference(HIE DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... 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 SΣ 1..1 code Mime type of the content, with charset etc.
Binding: Mime Types (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: CommonLanguages (preferred): IETF language tag
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data 0..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 1..1 HIEReference(HIE Encounter | HIE EpisodeOfCare) Context of the document content
.... event 0..* HIECodeableConcept 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 HIECodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting 0..1 HIECodeableConcept 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 1..1 HIEReference(HIE Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📍4.3.0 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.3.0 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.3.0 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.3.0 FHIR Std.
DocumentReference.content.​format Base preferred DocumentReference Format Code Set 📍4.3.0 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v7.0
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.3.0 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.3.0 FHIR Std.

Constraints

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.exists() and ('#'+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(uri) = '#').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()
dom-r4b warning DocumentReference.contained Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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()

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
... identifier SΣ 1..* Identifier Other identifiers for the document
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... docStatus Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ 1..1 HIECodeableConcept Kind of document (LOINC if possible)
Binding: FHIRDocumentTypeCodes (extensible)
... category SΣ 1..* HIECodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date SΣ 1..1 instant When this document reference was created
... author SΣ 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE Organization) Organization which maintains the document
... securityLabel Σ 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... 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 SΣ 1..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049)
Example General: text/plain; charset=UTF-8, image/png

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.3.0 FHIR Std.

Constraints

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.exists() and ('#'+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(uri) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DocumentReference A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 1..* Identifier Other identifiers for the document
.... use 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system 1..1 uri The namespace for the identifier value
.... value S 1..1 string The value that is unique
.... assigner S 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status S 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... category S 1..* HIECodeableConcept Categorization of document
... subject S 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date S 1..1 instant When this document reference was created
... author S 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE Organization) Organization which maintains the document
... relatesTo
.... target 1..1 HIEReference(HIE DocumentReference) Target of the relationship
... securityLabel 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... content S 1..* BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
..... contentType S 1..1 code Mime type of the content, with charset etc.
... context
.... encounter 1..1 HIEReference(HIE Encounter | HIE EpisodeOfCare) Context of the document content
.... event 0..* HIECodeableConcept Main clinical acts documented
.... facilityType 0..1 HIECodeableConcept Kind of facility where patient was seen
.... practiceSetting 0..1 HIECodeableConcept Additional details about where the content was created (e.g. clinical specialty)
.... sourcePatientInfo 1..1 HIEReference(HIE Patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.

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
... 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
Constraints: dom-r4b
... 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 SΣ 1..* Identifier Other identifiers for 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
.... use ?!Σ 1..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required)
.... type Σ 1..1 HIECodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible)
.... system Σ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner SΣ 0..1 HIEReference(HIE Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ 1..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ 1..1 HIECodeableConcept Kind of document (LOINC if possible)
Binding: FHIRDocumentTypeCodes (extensible)
... category SΣ 1..* HIECodeableConcept Categorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 HIEReference(HIE Patient) Who/what is the subject of the document
... date SΣ 1..1 instant When this document reference was created
... author SΣ 1..* HIEReference(HIE Practitioner | PractitionerRole | HIE Organization | HIE Patient) Who and/or what authored the document
... authenticator 1..1 HIEReference(HIE Practitioner | PractitionerRole | HIE Organization) Who/what authenticated the document
... custodian 0..1 HIEReference(HIE 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 HIEReference(HIE DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* HIECodeableConcept Document security-tags
Binding: All Security Labels (extensible)
... 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 SΣ 1..1 code Mime type of the content, with charset etc.
Binding: Mime Types (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: CommonLanguages (preferred): IETF language tag
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data 0..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 1..1 HIEReference(HIE Encounter | HIE EpisodeOfCare) Context of the document content
.... event 0..* HIECodeableConcept 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 HIECodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting 0..1 HIECodeableConcept 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 1..1 HIEReference(HIE Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📍4.3.0 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📦4.3.0 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📦4.3.0 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.3.0 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📦4.3.0 FHIR Std.
DocumentReference.type Base extensible FHIR Document Type Codes 📦4.3.0 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.3.0 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.3.0 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.3.0 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.3.0 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.3.0 FHIR Std.
DocumentReference.content.​format Base preferred DocumentReference Format Code Set 📍4.3.0 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v7.0
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.3.0 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.3.0 FHIR Std.

Constraints

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.exists() and ('#'+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(uri) = '#').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()
dom-r4b warning DocumentReference.contained Containing new R4B resources within R4 resources may cause interoperability issues if instances are shared with R4 systems ($this is Citation or $this is Evidence or $this is EvidenceReport or $this is EvidenceVariable or $this is MedicinalProductDefinition or $this is PackagedProductDefinition or $this is AdministrableProductDefinition or $this is Ingredient or $this is ClinicalUseDefinition or $this is RegulatedAuthorization or $this is SubstanceDefinition or $this is SubscriptionStatus or $this is SubscriptionTopic) implies (%resource is Citation or %resource is Evidence or %resource is EvidenceReport or %resource is EvidenceVariable or %resource is MedicinalProductDefinition or %resource is PackagedProductDefinition or %resource is AdministrableProductDefinition or %resource is Ingredient or %resource is ClinicalUseDefinition or %resource is RegulatedAuthorization or %resource is SubstanceDefinition or %resource is SubscriptionStatus or %resource is SubscriptionTopic)
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()

 

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