SGHI FHIR Profile 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/sil_fhir_profile_ig/ and changes regularly. See the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: SGHI DocumentReference Profile.

A reference to a document of any kind for any purpose.

Usages:

• Refer to this Profile: SGHI DocumentReference Profile.
• Examples for this Profile: DocumentReference/ExampleSGHIDocumentReference

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.

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Business identifiers for the document
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	Σ	0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	ΣC	1..1	string	The value that is unique Example General: 123456
assigner	Σ	1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	1..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..*	SGHICodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category	Σ	0..*	SGHICodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context	C	1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType	C	0..1	SGHICodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	0..1	SGHICodeableConcept	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).
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
custodian		1..1	SGHIReference(SGHI Organization)	Organization which maintains the document
securityLabel	Σ	0..*	SGHICodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier		1..*	Identifier	Business identifiers for the document
use		0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type		0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system		1..1	uri	The namespace for the identifier value
value		1..1	string	The value that is unique
assigner		1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
docStatus		1..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
modality		0..*	SGHICodeableConcept	Imaging modality used
type		1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category		0..*	SGHICodeableConcept	Categorization of document
subject		1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context		1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented
bodySite		0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType		0..1	SGHICodeableConcept	Kind of facility where patient was seen
practiceSetting		0..1	SGHICodeableConcept	Additional details about where the content was created (e.g. clinical specialty)
date		1..1	instant	When this document reference was created
author		1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
attester
mode		1..1	SGHICodeableConcept	personal | professional | legal | official
party		0..1	SGHIReference(SGHI Patient | SGHI Organization | SGHI Practitioner | SGHI PractitionerRole)	Who attested the document
custodian		1..1	SGHIReference(SGHI Organization)	Organization which maintains the document
relatesTo
code		1..1	SGHICodeableConcept	The relationship type with another document
target		1..1	SGHIReference(SGHI DocumentReference Profile.)	Target of the relationship
securityLabel		0..*	SGHICodeableConcept	Document security-tags
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	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 Additional Bindings Purpose CommonLanguages Starter
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	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Business 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	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	Σ	0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	ΣC	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	Σ	1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
version	Σ	0..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	1..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..*	SGHICodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category	Σ	0..*	SGHICodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context	C	1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType	C	0..1	SGHICodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	0..1	SGHICodeableConcept	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	Σ	1..1	instant	When this document reference was created
author	Σ	1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of 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
mode		1..1	SGHICodeableConcept	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	SGHIReference(SGHI Patient | SGHI Organization | SGHI Practitioner | SGHI PractitionerRole)	Who attested the document
custodian		1..1	SGHIReference(SGHI 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	SGHICodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	SGHIReference(SGHI DocumentReference Profile.)	Target of the relationship
description	Σ	0..1	markdown	Human-readable description
securityLabel	Σ	0..*	SGHICodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	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	Σ	1..1	Attachment	Where to access the document
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	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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: 11 elements

Structures

This structure refers to these other structures:

• SGHI CodeableConcept (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-codeableconcept)
• SGHI Reference (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-reference)
• SGHI Organization (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-organization)
• SGHI Appointment Profile (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-appointment)
• SGHI MedicationRequest (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-medicationrequest)
• SGHI ServiceRequest (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-servicerequest)
• SGHI Patient (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-patient)
• SGHI Encounter (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-encounter)
• SGHI EpisodeOfCare (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-episodeofcare)
• SGHI CodeableReference (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-codeable-reference)
• SGHI PractitionerRole (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-practitionerrole)
• SGHI Practitioner (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-practitioner)
• SGHI DocumentReference Profile. (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-documentreference)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Business identifiers for the document
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	Σ	0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	ΣC	1..1	string	The value that is unique Example General: 123456
assigner	Σ	1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	1..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..*	SGHICodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category	Σ	0..*	SGHICodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context	C	1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType	C	0..1	SGHICodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	0..1	SGHICodeableConcept	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).
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
custodian		1..1	SGHIReference(SGHI Organization)	Organization which maintains the document
securityLabel	Σ	0..*	SGHICodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
identifier		1..*	Identifier	Business identifiers for the document
use		0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type		0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system		1..1	uri	The namespace for the identifier value
value		1..1	string	The value that is unique
assigner		1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
docStatus		1..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
modality		0..*	SGHICodeableConcept	Imaging modality used
type		1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category		0..*	SGHICodeableConcept	Categorization of document
subject		1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context		1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented
bodySite		0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType		0..1	SGHICodeableConcept	Kind of facility where patient was seen
practiceSetting		0..1	SGHICodeableConcept	Additional details about where the content was created (e.g. clinical specialty)
date		1..1	instant	When this document reference was created
author		1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
attester
mode		1..1	SGHICodeableConcept	personal | professional | legal | official
party		0..1	SGHIReference(SGHI Patient | SGHI Organization | SGHI Practitioner | SGHI PractitionerRole)	Who attested the document
custodian		1..1	SGHIReference(SGHI Organization)	Organization which maintains the document
relatesTo
code		1..1	SGHICodeableConcept	The relationship type with another document
target		1..1	SGHIReference(SGHI DocumentReference Profile.)	Target of the relationship
securityLabel		0..*	SGHICodeableConcept	Document security-tags
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	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 Additional Bindings Purpose CommonLanguages Starter
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	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Business 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	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required)
type	Σ	0..1	SGHICodeableConcept	Description of identifier Binding: SGHI Standard Identifier Types (required)
system	Σ	1..1	uri	The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient
value	ΣC	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	Σ	1..1	SGHIReference(SGHI Organization)	Organization that issued id (may be just text)
version	Σ	0..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	SGHIReference(SGHI Appointment Profile | SGHI MedicationRequest | SGHI ServiceRequest)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	1..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..*	SGHICodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	SGHICodeableConcept	Kind of document (LOINC if possible) Binding: FHIRDocumentTypeCodes (required)
category	Σ	0..*	SGHICodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	SGHIReference(SGHI Patient)	Who/what is the subject of the document
context	C	1..*	SGHIReference(SGHI Appointment Profile | SGHI Encounter | SGHI EpisodeOfCare)	Context of the document content
event		0..*	SGHICodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	SGHICodeableReference(BodyStructure)	Body part included Binding: All LOINC Codes (required)
facilityType	C	0..1	SGHICodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	0..1	SGHICodeableConcept	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	Σ	1..1	instant	When this document reference was created
author	Σ	1..1	SGHIReference(SGHI Organization | SGHI PractitionerRole | SGHI Practitioner | SGHI Patient)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of 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
mode		1..1	SGHICodeableConcept	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	SGHIReference(SGHI Patient | SGHI Organization | SGHI Practitioner | SGHI PractitionerRole)	Who attested the document
custodian		1..1	SGHIReference(SGHI 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	SGHICodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	SGHIReference(SGHI DocumentReference Profile.)	Target of the relationship
description	Σ	0..1	markdown	Human-readable description
securityLabel	Σ	0..*	SGHICodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	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	Σ	1..1	Attachment	Where to access the document
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	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use From the FHIR Standard
DocumentReference.identifier.type	required	SGHIIdentifierTypes https://fhir.slade360.co.ke/fhir/ValueSet/sghi-identifier-types From this IG
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	Modality http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From http://tx.fhir.org/r5
DocumentReference.type	required	FHIRDocumentTypeCodes http://hl7.org/fhir/ValueSet/doc-typecodes From the FHIR Standard
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	required	AllLoincCodes(a valid code from LOINC) https://fhir.slade360.co.ke/fhir/ValueSet/all-loinc-codes From this IG
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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: 11 elements

Structures

This structure refers to these other structures:

• SGHI CodeableConcept (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-codeableconcept)
• SGHI Reference (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-reference)
• SGHI Organization (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-organization)
• SGHI Appointment Profile (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-appointment)
• SGHI MedicationRequest (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-medicationrequest)
• SGHI ServiceRequest (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-servicerequest)
• SGHI Patient (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-patient)
• SGHI Encounter (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-encounter)
• SGHI EpisodeOfCare (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-episodeofcare)
• SGHI CodeableReference (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-codeable-reference)
• SGHI PractitionerRole (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-practitionerrole)
• SGHI Practitioner (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-practitioner)
• SGHI DocumentReference Profile. (https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-documentreference)

Other representations of profile: CSV, Excel, Schematron