HL7 FHIR® Implementation Guide: Electronic Case Reporting (eCR) - US Realm
2.1.0 - STU 2 US

This page is part of the electronic Case Reporting (eCR) (v2.1.0: STU 2) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: RR DocumentReference

Official URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-documentreference Version: 2.1.0
Active as of 2020-07-02 Computable Name: RRDocumentReference

This profile represents external resources such as a text guidance, link to access forms for additional reporting needs, additional testing and/or laboratory testing needs, treatment and/or prevention resources, Public Health Agency contact information and general additional resources.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDocumentReferenceProfile

Summary

Mandatory: 4 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileRR Document Reference
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... priority S1..1CodeableConceptReportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority

... category S1..*CodeableConceptExternal Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type


... description S1..1stringExternal resource description

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileRR Document Reference
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... priority S1..1CodeableConceptReportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind 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'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... category SΣ1..*CodeableConceptExternal Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type


... subject SΣ1..1Reference(US Public Health Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | RelatedPerson | Device)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*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): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ1..1stringExternal resource description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument 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 SΣI1..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): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data SI0..1base64BinaryData inline, base64ed
..... url SΣI0..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 SΣ0..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): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileRR Document Reference
... priority 1..1CodeableConceptReportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority


... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... category Σ1..*CodeableConceptExternal Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type


... subject Σ1..1Reference(US Public Health Patient)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ0..*Reference(US Core Practitioner Profile)Who and/or what authored the document
... description Σ1..1stringExternal resource description
... content Σ1..*BackboneElementDocument referenced
.... attachment ΣI1..1AttachmentWhere to access the document
..... contentType Σ1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.

..... data I0..1base64BinaryData inline, base64ed
..... url ΣI0..1urlUri where the data can be found
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context Σ0..1BackboneElementClinical context of document
.... encounter 0..1Reference(US Core Encounter Profile)Context of the document content
.... period Σ0..1PeriodTime of service that is being documented

doco Documentation for this format

This structure is derived from USCoreDocumentReferenceProfile

Summary

Mandatory: 4 elements
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileRR Document Reference
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... priority S1..1CodeableConceptReportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority

... category S1..*CodeableConceptExternal Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type


... description S1..1stringExternal resource description

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileRR Document Reference
... id Σ0..1stringLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... priority S1..1CodeableConceptReportability Response Priority
URL: http://hl7.org/fhir/us/ecr/StructureDefinition/rr-priority-extension
Binding: Reportability Priority (eCR) (extensible): Reportability Priority


... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind 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'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... category SΣ1..*CodeableConceptExternal Resource Type
Binding: External Resource Type (eCR) (extensible): External Resource Type


... subject SΣ1..1Reference(US Public Health Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | RelatedPerson | Device)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*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): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ1..1stringExternal resource description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument 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 SΣI1..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): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data SI0..1base64BinaryData inline, base64ed
..... url SΣI0..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 SΣ0..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): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Min Binding: US Core Clinical Note Type
DocumentReference.categoryextensibleRRVS_ExternalResourceType_eCR
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types
DocumentReference.content.attachment.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePathDetailsRequirements
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 or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).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()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6Best PracticeDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1errorDocumentReference.metaAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.implicitRulesAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.textAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.extension:priorityAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.extension:priorityMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.masterIdentifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.identifierAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.statusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.docStatusAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.typeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.categoryAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.subjectAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.dateAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.authorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.authenticatorAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.custodianAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.relatesToAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.relatesTo.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.relatesTo.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.relatesTo.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.relatesTo.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.relatesTo.codeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.relatesTo.targetAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.descriptionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.securityLabelAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.contentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.content.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.content.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.content.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.content.attachmentAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
ele-1errorDocumentReference.content.attachment.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.content.attachment.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.content.attachment.contentTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.languageAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.dataAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.urlAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.sizeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.hashAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.titleAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.attachment.creationAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.content.formatAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.contextAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.extensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.context.extensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.context.modifierExtensionAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1errorDocumentReference.context.modifierExtensionMust have either extensions or value[x], not both
: extension.exists() != value.exists()
ele-1errorDocumentReference.context.encounterAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.eventAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.periodAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.facilityTypeAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.practiceSettingAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.sourcePatientInfoAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ele-1errorDocumentReference.context.relatedAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())