This page is part of the Non-patient File Sharing (NPFS) (v2.2.0: Publication) based on FHIR R4. This is the current published version. For a full list of available versions, see the Directory of published versions

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Resource Profile: NPFS DocumentReference

A profile on the DocumentReference resource for NPFS.

Usage:

• Use this Resource Profile: NPFS Create Document Bundle, NPFS Replace Document Bundle and NPFS Update Document Bundle
• Examples for this Resource Profile: DocumentReference/12345 and DocumentReference/ex-DocumentReferenceMinimal

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference			DocumentReference
id	S	0..1	id	Logical id of this artifact
identifier	S	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
type		1..1	CodeableConcept	Kind of document (LOINC if possible)
category		1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
subject		0..0
date		1..1	instant	When this document reference was created
author		1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
relatesTo	S	0..*	BackboneElement	Relationships to other documents
securityLabel	S	0..*	CodeableConcept	Document security-tags
content
attachment
contentType		1..1	code	Mime type of the content, with charset etc.
language	S	0..1	code	Required if known
data		0..0
url		1..1	url	Uri where the data can be found
size		1..1	unsignedInt	Number of bytes of content (if url provided)
hash		1..1	base64Binary	Hash of the data (sha-1, base64ed)
creation	S	0..1	dateTime	Date attachment was first created
format	S	1..1	Coding	Format/content rules for the document
context
encounter		0..0
period	S	0..1	Period	Time of service that is being documented
facilityType	S	0..1	CodeableConcept	Kind of facility where patient was seen
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty)
sourcePatientInfo		0..0
related		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.category	extensible	DocumentReferenceCategory

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	SΣ	0..1	id	Logical id of this artifact
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored 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	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): 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
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	0..1	code	Required if known Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding 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	1..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	1..1	base64Binary	Hash of the data (sha-1, base64ed)
creation	SΣ	0..1	dateTime	Date attachment was first created
format	SΣ	1..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	extensible	DocumentReferenceCategory
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	SΣ	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: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	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	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): 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
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	0..1	code	Required if known Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding 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	1..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	1..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	0..1	dateTime	Date attachment was first created
format	SΣ	1..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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
facilityType	S	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	extensible	DocumentReferenceCategory
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 9 elements
Must-Support: 10 elements
Prohibited: 5 elements

Slices

This structure defines the following Slices:

• The element DocumentReference.identifier is sliced based on the value of value:use

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference			DocumentReference
id	S	0..1	id	Logical id of this artifact
identifier	S	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
type		1..1	CodeableConcept	Kind of document (LOINC if possible)
category		1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
subject		0..0
date		1..1	instant	When this document reference was created
author		1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
relatesTo	S	0..*	BackboneElement	Relationships to other documents
securityLabel	S	0..*	CodeableConcept	Document security-tags
content
attachment
contentType		1..1	code	Mime type of the content, with charset etc.
language	S	0..1	code	Required if known
data		0..0
url		1..1	url	Uri where the data can be found
size		1..1	unsignedInt	Number of bytes of content (if url provided)
hash		1..1	base64Binary	Hash of the data (sha-1, base64ed)
creation	S	0..1	dateTime	Date attachment was first created
format	S	1..1	Coding	Format/content rules for the document
context
encounter		0..0
period	S	0..1	Period	Time of service that is being documented
facilityType	S	0..1	CodeableConcept	Kind of facility where patient was seen
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty)
sourcePatientInfo		0..0
related		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.category	extensible	DocumentReferenceCategory

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	SΣ	0..1	id	Logical id of this artifact
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored 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	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): 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
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	0..1	code	Required if known Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding 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	1..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	1..1	base64Binary	Hash of the data (sha-1, base64ed)
creation	SΣ	0..1	dateTime	Date attachment was first created
format	SΣ	1..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	extensible	DocumentReferenceCategory
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	SΣ	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: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	1..1	CodeableConcept	Categorization of document Binding: NPFS DocumentReference category (extensible)
date	Σ	1..1	instant	When this document reference was created
author	Σ	1..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	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	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): 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
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	0..1	code	Required if known Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding 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	1..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	1..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	0..1	dateTime	Date attachment was first created
format	SΣ	1..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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
facilityType	S	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	S	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	extensible	DocumentReferenceCategory
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 9 elements
Must-Support: 10 elements
Prohibited: 5 elements

Slices

This structure defines the following Slices:

• The element DocumentReference.identifier is sliced based on the value of value:use

Other representations of profile: CSV, Excel, Schematron