US Core (R4) Implementation Guide STU 3 Ballot

This page is part of the US Core (v2.1.0: STU3 Ballot 1) based on FHIR R4. The current version which supercedes this version is 5.0.1. For a full list of available versions, see the Directory of published versions

This is a ballot version of the USCore Implementation Guide. The current version is STU 2. See the Directory of published versions

StructureDefinition-new-us-core-documentreference

This profile sets minimum expectations for searching and fetching Clinical Notes using the DocumentReference resource. It is built upon the US Core DocumentReference profile. It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the DocumentReference resource when using this profile.

Example Usage Scenarios:

The following are example usage scenarios for the Argonaut Clinical Notes profile:

  • Query for a specific Clinical Note type (e.g. Discharge Summary)
  • Query for all Clinical Notes belonging to a Patient
  • Write a new Note to a Patient’s Chart
Mandatory Data Elements and Terminology

The following data-elements are mandatory (i.e data MUST be present). These are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Profile Definition below provides the formal summary, definitions, and terminology requirements.

Each Clinical Note DocumentReference must have:

  1. a category of the DocumentReference, referred to as class
  2. an author

Additional mandatory elements inherited from US Core DocumentReference

  1. a patient
  2. a code describing the type of document
  3. a status
  4. date and time the reference was created (STU3 requirement, removed in R4)
  5. an https address where the document can be retrieved

In addition it should have (if available):

  1. the organization responsible for the document, referred to as custodian.

Additional Inherited from US Core DocumentReference

  1. a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
  2. a document creation date
  3. a code identifying the specific details about the format of the document — over and above the content’s MIME type
  4. the patient encounter date that is being referenced

Profile specific implementation guidance:

The DocumentReference.type binding must support at a minimum the 5 Common Clinical Notes and may extend to the full HITSP C80 Table 2-144 Document Class Value Set Definition

Examples
  • TBD

Note that the Differential Table View displayed below is the Clinical Notes Profile, and the SnapShot Table View combines the the Clinical Notes Profile with US Core DocumentReference and FHIR core.

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: http://hl7.org/fhir/us/core/StructureDefinition/new-us-core-documentreference

Published on Fri Nov 02 00:00:00 AEDT 2018 as a active by HL7 US Realm Steering Committee.

This profile builds on USCoreDocumentReferenceProfile

Summary of the Mandatory Requirements
...todo...
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*New US Core DocumentReference Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..1IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (required)
... category SΣ1..*CodeableConceptCategorization of document
Binding: US Core DocumentReferences Category Value Set (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | Organization)Who/what authenticated the document
... custodian S0..1Reference(US Core Organization Profile)Organization which maintains the document
... relatesTo ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required)
Example General': text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Example General': en-AU
..... data 0..1base64BinaryData inline, base64ed
..... url SΣ1..1urlUri where the data can be found
Example General': http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General': Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣI0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example)
.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example)
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Summary

Mandatory: 1 element
Must-Support: 3 elements

Structures

This structure refers to these other structures:

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*New US Core DocumentReference Profile
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..1IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (required)
... category SΣ1..*CodeableConceptCategorization of document
Binding: US Core DocumentReferences Category Value Set (extensible)
... subject SΣ1..1Reference(US Core Patient Profile)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | Organization)Who/what authenticated the document
... custodian S0..1Reference(US Core Organization Profile)Organization which maintains the document
... relatesTo ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required)
Example General': text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Example General': en-AU
..... data 0..1base64BinaryData inline, base64ed
..... url SΣ1..1urlUri where the data can be found
Example General': http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General': Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣI0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example)
.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example)
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron


Quick Start

Below is an overview of the required set of RESTful FHIR interactions - for example, search and read operations - for this profile. See the Conformance requirements for a complete list of supported RESTful interactions for this IG.

Retrieve a Clinical Note with a given DocumentReference id:

GET [base]/DocumentReference/[id]

Example: GET [base]/DocumentReference/2169591

Support: Mandatory to support retrieve by a specific DocumentReference id.

Implementation Notes: This will return a pointer to the Binary resource which then can be retrieved using:

GET [base]/Binary/[id]

All other searches expect this two step process of locating the Clinical Note, and then retrieving the Binary.

Retrieve all Clinical Notes for a given Patient:

GET [base]/DocumentReference?patient=[id]&class=clinical-note

Example: GET [base]/DocumentReference?patient=1235541&class=clinical-note

Support: Mandatory to support search by patient to locate all Clinical Notes.

Implementation Notes: Search for all Clinical Notes for a patient (how to search by reference) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Retrieve a Patient’s Clinical Notes by Searching with a date range:

GET [base]/DocumentReference?patient=[id]&class=clinical-note&created=[date]

Example: GET [base]/DocumentReference?patient=1316024&class=clinical-note&created=ge2018-04-11

Support: Mandatory to support search by date range.

Implementation Notes: Search for all Clinical Notes for a patient (how to search by reference) for a date range (how to search by date) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Retrieve a specific Note type for a Patient:

GET [base]/DocumentReference?patient=[id]&type=[note type (LOINC)]

Example: GET [base]/DocumentReference?patient=1316024&type=http://loinc.org 18842-5

Support: Mandatory to support search by Note type.

Implementation Notes: Search for a specific Note type (how to search by token) for a patient (how to search by reference) fetches a bundle of all DocumentReference resources for the specified patient. Retrieving specific Notes will require a secondary request on the Binary resource.

Write new note to a Patient’s Chart:

POST [base]/DocumentReference

An example to demonstrate writing a note to the server.

Clinical Note

POST [base]/DocumentReference
Request Headers:
 content-type: "application/json"
 prefer: "return=REPRESENTATION"
 accept: "application/fhir+json"
Request Body:
 {
   "resourceType": "DocumentReference",
   "type": {
       "coding": [
           {
               "system": "http://loinc.org",
               "code": "18842-5",
               "display": "Discharge Summary"
           }
       ],
       "text": "Discharge Summary"
   },
   "subject": {
       "reference": "[base]/Patient/eso2MXsmcJloTEUEls5DzbA3"
   },
   "content": [{"attachment": {
       "contentType": "text/plain",
       "data": "Tm8gYWN0aXZpdHkgcmVzdHJpY3Rpb24sIHJlZ3VsYXIgZGlldCwgZm9sbG93IHVwIGluIHR3byB0byB0aHJlZSB3ZWVrcyB3aXRoIHByaW1hcnkgY2FyZSBwcm92aWRlci4="
   } }],
   "context": {"encounter": {"reference": "[base]/Encounter/eIOY6XJQw0hvmvCqTtkg6vQ3"} }
 }

Note Content

The content is Base64 encoded and states: “No activity restriction, regular diet, follow up in two to three weeks with primary care provider.”


Support: Mandatory to support write capability.