SGHI FHIR Profile Implementation Guide
0.1.0 - ci-build

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

Resource Profile: SGHI DocumentReference Profile.

Official URL: https://fhir.slade360.co.ke/fhir/StructureDefinition/sghi-documentreference Version: 0.1.0
Draft as of 2025-12-02 Computable Name: SGHIDocumentReference

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

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 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
.... 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 status ?!Σ 1..1 code current | superseded | entered-in-error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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
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 required 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 v7.0
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG
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.securityLabel Base example Example set of Security Labels 📍5.0.0 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 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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
DocumentReference.type Base required FHIR Document Type Codes 📦5.0.0 FHIR Std.
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base required All Languages 📍5.0.0 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
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 required 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 v7.0
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG
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.content.​profile.value[x] Base preferred HL7 ValueSet of Format Codes for use with Document Sharing 📦2.1.0 THO v7.0

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 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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
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 required 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 v7.0
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG
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.securityLabel Base example Example set of Security Labels 📍5.0.0 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 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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
DocumentReference.type Base required FHIR Document Type Codes 📦5.0.0 FHIR Std.
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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 BindingsPurpose
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)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base required All Languages 📍5.0.0 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📦5.0.0 FHIR Std.
DocumentReference.identifier.​type Base required SGHI Standard Identifier Types 📦0.1.0 This IG
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 required 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 v7.0
DocumentReference.bodySite Base required All LOINC Codes 📦0.1.0 This IG
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.content.​profile.value[x] Base preferred HL7 ValueSet of Format Codes for use with Document Sharing 📦2.1.0 THO v7.0

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 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()

 

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