| Left: | US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference) |
| Right: | US Core DocumentReference Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference) |
| Error | StructureDefinition.version | Values for version differ: '3.1.1' vs '6.0.0-ballot' |
| Information | StructureDefinition.date | Values for date differ: '2020-07-02' vs '2022-04-20' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'HL7 US Realm Steering Committee' vs 'HL7 International - Cross-Group Projects' |
| Warning | DocumentReference | Elements differ in definition: 'This is a basic constraint on DocumentRefernce for use in the US Core IG.' vs '\-' |
| Warning | DocumentReference | Elements differ in comments: 'Usually, this is used for documents other than those defined by FHIR.' vs '\-' |
| Warning | DocumentReference.category | Elements differ in binding.description: 'The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.' vs 'High-level kind of a clinical document at a macro level.' |
| Warning | DocumentReference.custodian | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | DocumentReference.content.attachment.contentType | Element minimum cardinalities differ: '1' vs '0' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/DocumentReference | ||
| copyright | Used by permission of HL7 International, all rights reserved Creative Commons License |
| |
| date | 2020-07-02 | 2022-04-20 |
|
| description | The document reference profile used in US Core. | To promote interoperability and adoption through common implementation, this profile sets minimum expectations for searching and fetching patient documents including Clinical Notes using the DocumentReference resource. It identifies the mandatory core elements, extensions, vocabularies and value sets which **SHALL** be present in the DocumentReference resource when using this profile. It provides the floor for standards development for specific use cases. Prior to reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of US Core DocumentReference Profile and US Core DiagnosticReport Profile for Report and Note exchange. |
|
| experimental | false | ||
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | urn:iso:std:iso:3166#US | ||
| kind | resource | ||
| name | USCoreDocumentReferenceProfile | ||
| publisher | HL7 US Realm Steering Committee | HL7 International - Cross-Group Projects |
|
| purpose | |||
| status | active | ||
| title | US Core DocumentReference Profile | ||
| type | DocumentReference | ||
| url | http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | ||
| version | 3.1.1 | 6.0.0-ballot |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | L Type | L Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 DocumentReference | 0..* | DocumentReference | A reference to a document | 0..* | DocumentReference | A reference to a document |
| ||||||||||
 id | Σ | 0..1 | string | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!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.
| 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 | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
 extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | |||||||||
| identifier | SΣ | 0..* | Identifier | Other identifiers for the document | SΣ | 0..* | Identifier | Other identifiers for the document | |||||||||
| status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | |||||||||
| docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||||||
| type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: USCoreDocumentReferenceType (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| |||||||||
| category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: USCoreDocumentReferenceCategory (extensible): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes. | SΣ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
| ||||||||
| subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | SΣ | 1..1 | Reference(US Core Patient Profile) | Who/what is the subject of the document | |||||||||
| date | SΣ | 0..1 | instant | When this document reference was created | SΣ | 0..1 | instant | When this document reference was created | |||||||||
| author | SΣ | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document | SΣ | 0..* | Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | Who and/or what authored the document | |||||||||
| authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||||||||
| custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document | 0..1 | Reference(Organization) | Organization which maintains the document |
| |||||||||
| relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | Σ | 0..* | BackboneElement | Relationships to other documents | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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. | 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 | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | |||||||||
| description | Σ | 0..1 | string | Human-readable description | Σ | 0..1 | string | Human-readable description | |||||||||
| securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||||||
| content | SΣ | 1..* | BackboneElement | Document referenced | SΣ | 1..* | BackboneElement | Document referenced | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| attachment | SΣC | 1..1 | Attachment | Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | SΣC | 1..1 | Attachment | Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | 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: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | SΣ | 0..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 | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | |||||||||
| data | SC | 0..1 | base64Binary | Data inline, base64ed | SC | 0..1 | base64Binary | Data inline, base64ed | |||||||||
| url | SΣC | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | SΣC | 0..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) | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | |||||||||
| hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | 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 | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||||||
| creation | Σ | 0..1 | dateTime | Date attachment was first created | Σ | 0..1 | dateTime | Date attachment was first created | |||||||||
| format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | |||||||||
| context | SΣ | 0..1 | BackboneElement | Clinical context of document | SΣ | 0..1 | BackboneElement | Clinical context of document | |||||||||
 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| encounter | S | 0..1 | Reference(US Core Encounter Profile) | Context of the document content | S | 0..1 | Reference(US Core Encounter Profile) | 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. | 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 | SΣ | 0..1 | Period | Time of service that is being documented | |||||||||
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||||||||
| practiceSetting | 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). | 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). | |||||||||||
| sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | 0..1 | Reference(Patient) | Patient demographics from source | |||||||||||
| related | 0..* | Reference(Resource) | Related identifiers or resources | 0..* | Reference(Resource) | Related identifiers or resources | |||||||||||
| Documentation for this format | |||||||||||||||||