Mobile access to Health Documents (MHD)
4.2.2 - Trial-Implementation
This page is part of the IHE Mobile Access to Health Documents (v4.2.2: Publication) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Official URL: https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.Comprehensive.DocumentReference | Version: 4.2.2 | |||
Active as of 2024-05-18 | Computable Name: ComprehensiveDocumentReference |
A profile on the DocumentReference resource for MHD Comprehensive Option with Contained (not UnContained), compatible with XDS-on-FHIR and XCA use.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from UnContainedComprehensiveDocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |
author | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | |
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |
context | ||||
sourcePatientInfo | 1..1 | Reference(Patient) {c} | Patient demographics from source | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
masterIdentifier | 1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
Slices for identifier | SΣ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
identifier:entryUUID | 0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
securityLabel | SΣ | 1..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | Σ | 1..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 | ||||
contentType | Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
creation | SΣ | 1..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
context | Σ | 1..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
facilityType | S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
practiceSetting | S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | ||||
sourcePatientInfo | S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats from this IG | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
masterIdentifier | 1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
Slices for identifier | SΣ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
identifier:entryUUID | 0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
custodian | 0..1 | Reference(Organization) | Organization which maintains the document | |||||
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
description | Σ | 0..1 | string | Human-readable description | ||||
securityLabel | SΣ | 1..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | Σ | 1..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 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
url | Σ | 1..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 | SΣ | 1..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
context | Σ | 1..1 | BackboneElement | Clinical context of document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | |||||
event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
facilityType | S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
practiceSetting | S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | ||||
sourcePatientInfo | S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats from this IG | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard | ||||
DocumentReference.context.sourcePatientInfo.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard |
This structure is derived from UnContainedComprehensiveDocumentReference
Differential View
This structure is derived from UnContainedComprehensiveDocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |
author | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | |
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |
context | ||||
sourcePatientInfo | 1..1 | Reference(Patient) {c} | Patient demographics from source | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
masterIdentifier | 1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
Slices for identifier | SΣ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
identifier:entryUUID | 0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
securityLabel | SΣ | 1..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | Σ | 1..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 | ||||
contentType | Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
creation | SΣ | 1..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
context | Σ | 1..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
facilityType | S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
practiceSetting | S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | ||||
sourcePatientInfo | S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats from this IG | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | UnContainedComprehensiveDocumentReference | A reference to a document | |||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
security | Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
tag | Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
masterIdentifier | 1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
Slices for identifier | SΣ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
identifier:entryUUID | 0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) {c} | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
custodian | 0..1 | Reference(Organization) | Organization which maintains the document | |||||
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
description | Σ | 0..1 | string | Human-readable description | ||||
securityLabel | SΣ | 1..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | Σ | 1..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 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
language | SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
url | Σ | 1..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 | SΣ | 1..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
context | Σ | 1..1 | BackboneElement | Clinical context of document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | |||||
event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
start | ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
end | ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
facilityType | S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | ||||
practiceSetting | S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | ||||
sourcePatientInfo | S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
display | Σ | 0..1 | string | Text alternative for the resource | ||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats from this IG | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard | ||||
DocumentReference.context.sourcePatientInfo.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard |
This structure is derived from UnContainedComprehensiveDocumentReference
Other representations of profile: CSV, Excel, Schematron