RIVO-Noord Zorgviewer Implementation Guide
1.1.0 - sprint35 Netherlands flag

RIVO-Noord Zorgviewer Implementation Guide - Local Development build (v1.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DocumentReference

Official URL: http://hl7.nl/fhir/zorgviewer/StructureDefinition/DocumentReference Version: 1.1.0
Draft as of 2024-06-21 Computable Name: DocumentReference

Verwijzingen naar documenten

Dit Profiel is het resultaat van de vergelijking tussen de zib2017 FHIR Profiel en de implementaties in Epic en Chipsoft. De elementen die in ieder geval in alle output beschikbaar zullen zijn. Voornamelijk bedoeld voor houvast van een client en voor validatie van output.

User-Interface guidance

Een schets van het scherm met labels en sortering informatie:

Kolom definities:

Kolom label FHIR Path FHIR Type Zib element Toelichting of regels
Bron .meta.extension[system="http://hl7.org/fhir/4.0/StructureDefinition/extension-Meta.source"].valueUri string nvt Lookup adhv uri (AGB-Z of OID) <adressering-base>/Organization?identifier=<.meta.tag.code> en gebruik dan Organization.name
Datum .context.period.start of .indexed indien .context.period.start leeg is dateTime nvt N.B. tijd is GMT, dus omzetten naar CET. Ter info: indien datum uit ​.indexed komt, wordt deze gemarkeerd met een icoontje (i)
Beschrijving .description​ string nvt Tijdelijk voor Zorgplatform: gebruik content.attachment.title voor de beschrijving van documenten inclusief het strippen van de .pdfextensie
Auteur .author.display string nvt Tijdelijk voor Zorgplatform: indien .author.display is gevuld met een IOD, dan wordt het veld gevuld met Auteur niet bekend

Document soorten herkennen

class (higher level grouping) type (http://loinc.org) descriptions
correspondence
Correspondentie
Healthcare communication Document (56444-3) Correspondentie, Patiëntenbrief, Verwijsbrief, Poliklinische brief, Artsenbrief
imaging-result
Imaging result
Procedure note (28570-0) Radiologie verslag
clinical-note
Notitie
Epic clinical-note(s) types from https://vendorservices.epic.com/Sandbox/Index?api=865
  • Discharge Documentation (18842-5)
  • Consultation (11488-4)
  • History & Physical (34117-2)
  • Progress Note (11506-3)
  • Procedure Note (28570-0)
  • Emergency Department Note (34111-5)
  • Nurse Note (34746-8)
  • Discharge Instructions (74213-0)
  • Risk assessment and screening note (75492-9)
  • OR Note (11504-8)
  • Miscellaneous Notes (34109-9)

Zie het Excelbestand tab “classCode+decision tree” voor LOINC codes: Nationale XDS metadataset

Request

  1. Opvragen (search) alle documenten

    GET <ontsluiten-bronsysteem-base>/DocumentReference?patient=<fhir_patient_id>

Bronsysteem herkennen

De Zorgviewer-backend of Ontsluiten bronsysteem MOET na bevragen van het bronsysteem aan elk resultaat resource een meta-tag toevoegen met de VEKTIS AGB-Z code of de HL7 NL OID van de zorgaanbieder. Dit wordt vervolgens gebruikt in de “Bron” kolom in de Zorgviewer-frontend. N.B. We gebruiken hier een pre-adopt van de FHIR R4 Meta.source.

Toevoegen aan elke response, dus per resource (bij een read) of per Bundle (bij een search):

"meta": {
    "extension": [ {
        "url": "http://hl7.org/fhir/4.0/StructureDefinition/extension-Meta.source",
        "valueUri": "urn:oid:2.16.840.1.113883.2.4.3.8"
    } ]
}

Optioneel: Elke entry van een search response Bundle bevat een referentie naar de bijbehorende Patient (<resource>.subject|patient). Elke patient heeft een Patient.managingOrganization en in de gerefereerde Organization.identifier staat vervolgens o.a. de OID van het bronsysyeem. Of je gebruikt de identifiers om een volledige Organization op te zoeken in het adresboek en zie inhoud hier.

Usage:

  • This Resource Profile is not used by any profiles in this Implementation Guide

Formal Views of Profile Content

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

This structure is derived from Nictiz.IHE.MHD.Minimal.DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... status S 1..1 code current | superseded | entered-in-error
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
... class S 0..1 CodeableConcept Categorization of document
... description S 0..1 string Human-readable description (title)
... content 1..1 BackboneElement Document referenced
.... attachment SC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... contentType S 1..1 code Mime type of the content, with charset etc.
..... url S 1..1 uri Uri where the data can be found
... context
.... period
..... start S 0..1 dateTime Starting time with inclusive boundary

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type Value Set (preferred): Precise type of clinical document.

... class SΣ 0..1 CodeableConcept Categorization of document
Binding: Document Class Value Set (example): High-level kind of a clinical document at a macro level.

... subject SΣ 0..1 Reference(Patient) {r, b} Who/what is the subject of the document
... indexed SΣ 1..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | Organization) {c} Who and/or what authored the document
... relatesTo ?!SΣ 0..* BackboneElement Relationships to other documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... 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 SΣ 0..1 string Human-readable description (title)
... securityLabel SΣ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... attachment SΣC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: mimetypes (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 Human language of the content (BCP-47)
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url SΣ 1..1 uri Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... period SΣ 0..1 Period Time of service that is being documented
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
.... facilityType SΣ 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set (example): XDS Facility Type.

.... practiceSetting SΣ 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo SΣ 0..1 Reference() {c} Patient demographics from source

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typepreferredDocument Type Value Set
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.classexampleDocument Class Value Set
http://hl7.org/fhir/ValueSet/c80-doc-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredhttp://hl7.org/fhir/ValueSet/mimetypes
http://hl7.org/fhir/ValueSet/mimetypes
DocumentReference.content.attachment.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatpreferredIHE.FormatCode.vs (a valid code from urn:oid:1.3.6.1.4.1.19376.1.2.3)
http://ihe.net/fhir/ValueSet/IHE.formatcode.vs
DocumentReference.context.facilityTypeexampleFacility Type Code Value Set
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePractice Setting Code Value Set
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-1errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
dom-4errorDocumentReferenceIf 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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional Content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type Value Set (preferred): Precise type of clinical document.

... class SΣ 0..1 CodeableConcept Categorization of document
Binding: Document Class Value Set (example): High-level kind of a clinical document at a macro level.

... subject SΣ 0..1 Reference(Patient) {r, b} Who/what is the subject of the document
... indexed SΣ 1..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | Organization) {c} Who and/or what authored the document
... authenticator Σ 0..1 Reference() {c} Who/what authenticated the document
... relatesTo ?!SΣ 0..* BackboneElement Relationships to other documents
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... 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 SΣ 0..1 string Human-readable description (title)
... securityLabel SΣ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... attachment SΣC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... id 0..1 string xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: mimetypes (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 Human language of the content (BCP-47)
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url SΣ 1..1 uri 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
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 0..1 BackboneElement Clinical context of document
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... encounter Σ 0..1 Reference(Encounter) Context of the document content
.... event Σ 0..* CodeableConcept Main clinical acts documented
Binding: 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 xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType SΣ 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set (example): XDS Facility Type.

.... practiceSetting SΣ 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo SΣ 0..1 Reference() {c} Patient demographics from source
.... related Σ 0..* BackboneElement Related identifiers or resources
..... id 0..1 string xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
..... identifier Σ 0..1 Identifier Identifier of related objects or events
..... ref Σ 0..1 Reference(Resource) Related Resource

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typepreferredDocument Type Value Set
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.classexampleDocument Class Value Set
http://hl7.org/fhir/ValueSet/c80-doc-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredhttp://hl7.org/fhir/ValueSet/mimetypes
http://hl7.org/fhir/ValueSet/mimetypes
DocumentReference.content.attachment.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatpreferredIHE.FormatCode.vs (a valid code from urn:oid:1.3.6.1.4.1.19376.1.2.3)
http://ihe.net/fhir/ValueSet/IHE.formatcode.vs
DocumentReference.context.eventexamplev3 Code System ActCode
http://hl7.org/fhir/ValueSet/v3-ActCode
from the FHIR Standard
DocumentReference.context.facilityTypeexampleFacility Type Code Value Set
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePractice Setting Code Value Set
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-1errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
dom-4errorDocumentReferenceIf 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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'

This structure is derived from Nictiz.IHE.MHD.Minimal.DocumentReference

Summary

Mandatory: 1 element
Must-Support: 9 elements

Differential View

This structure is derived from Nictiz.IHE.MHD.Minimal.DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... status S 1..1 code current | superseded | entered-in-error
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
... class S 0..1 CodeableConcept Categorization of document
... description S 0..1 string Human-readable description (title)
... content 1..1 BackboneElement Document referenced
.... attachment SC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... contentType S 1..1 code Mime type of the content, with charset etc.
..... url S 1..1 uri Uri where the data can be found
... context
.... period
..... start S 0..1 dateTime Starting time with inclusive boundary

doco Documentation for this format

Constraints

IdGradePath(s)DetailsRequirements
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type Value Set (preferred): Precise type of clinical document.

... class SΣ 0..1 CodeableConcept Categorization of document
Binding: Document Class Value Set (example): High-level kind of a clinical document at a macro level.

... subject SΣ 0..1 Reference(Patient) {r, b} Who/what is the subject of the document
... indexed SΣ 1..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | Organization) {c} Who and/or what authored the document
... relatesTo ?!SΣ 0..* BackboneElement Relationships to other documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... 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 SΣ 0..1 string Human-readable description (title)
... securityLabel SΣ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... attachment SΣC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: mimetypes (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 Human language of the content (BCP-47)
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url SΣ 1..1 uri Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... period SΣ 0..1 Period Time of service that is being documented
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
.... facilityType SΣ 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set (example): XDS Facility Type.

.... practiceSetting SΣ 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo SΣ 0..1 Reference() {c} Patient demographics from source

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typepreferredDocument Type Value Set
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.classexampleDocument Class Value Set
http://hl7.org/fhir/ValueSet/c80-doc-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredhttp://hl7.org/fhir/ValueSet/mimetypes
http://hl7.org/fhir/ValueSet/mimetypes
DocumentReference.content.attachment.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatpreferredIHE.FormatCode.vs (a valid code from urn:oid:1.3.6.1.4.1.19376.1.2.3)
http://ihe.net/fhir/ValueSet/IHE.formatcode.vs
DocumentReference.context.facilityTypeexampleFacility Type Code Value Set
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePractice Setting Code Value Set
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-1errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
dom-4errorDocumentReferenceIf 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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C 0..* Nictiz.IHE.MHD.Minimal.DocumentReference A reference to a document
zv-dr-1: Only status is current final documents are expected.
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional Content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type Value Set (preferred): Precise type of clinical document.

... class SΣ 0..1 CodeableConcept Categorization of document
Binding: Document Class Value Set (example): High-level kind of a clinical document at a macro level.

... subject SΣ 0..1 Reference(Patient) {r, b} Who/what is the subject of the document
... indexed SΣ 1..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | Organization) {c} Who and/or what authored the document
... authenticator Σ 0..1 Reference() {c} Who/what authenticated the document
... relatesTo ?!SΣ 0..* BackboneElement Relationships to other documents
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... 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 SΣ 0..1 string Human-readable description (title)
... securityLabel SΣ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... attachment SΣC 1..1 Attachment Where to access the document
zv-dr-2: Only pdf documents are expected through the url
..... id 0..1 string xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: mimetypes (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 Human language of the content (BCP-47)
Binding: Common Languages (extensible): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... url SΣ 1..1 uri 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
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred)
... context Σ 0..1 BackboneElement Clinical context of document
.... id 0..1 string xml:id (or equivalent in JSON)
.... extension 0..* Extension Additional Content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
.... encounter Σ 0..1 Reference(Encounter) Context of the document content
.... event Σ 0..* CodeableConcept Main clinical acts documented
Binding: 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 xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end ΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType SΣ 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set (example): XDS Facility Type.

.... practiceSetting SΣ 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo SΣ 0..1 Reference() {c} Patient demographics from source
.... related Σ 0..* BackboneElement Related identifiers or resources
..... id 0..1 string xml:id (or equivalent in JSON)
..... extension 0..* Extension Additional Content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored
..... identifier Σ 0..1 Identifier Identifier of related objects or events
..... ref Σ 0..1 Reference(Resource) Related Resource

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typepreferredDocument Type Value Set
http://hl7.org/fhir/ValueSet/c80-doc-typecodes
from the FHIR Standard
DocumentReference.classexampleDocument Class Value Set
http://hl7.org/fhir/ValueSet/c80-doc-classcodes
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredhttp://hl7.org/fhir/ValueSet/mimetypes
http://hl7.org/fhir/ValueSet/mimetypes
DocumentReference.content.attachment.languageextensibleCommon Languages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatpreferredIHE.FormatCode.vs (a valid code from urn:oid:1.3.6.1.4.1.19376.1.2.3)
http://ihe.net/fhir/ValueSet/IHE.formatcode.vs
DocumentReference.context.eventexamplev3 Code System ActCode
http://hl7.org/fhir/ValueSet/v3-ActCode
from the FHIR Standard
DocumentReference.context.facilityTypeexampleFacility Type Code Value Set
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePractice Setting Code Value Set
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-1errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
dom-4errorDocumentReferenceIf 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()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
zv-dr-1errorDocumentReferenceOnly status is current final documents are expected.
: status='current'
zv-dr-2warningDocumentReference.content.attachmentOnly pdf documents are expected through the url
: contentType='application/pdf'

This structure is derived from Nictiz.IHE.MHD.Minimal.DocumentReference

Summary

Mandatory: 1 element
Must-Support: 9 elements

 

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