MCC eCare Plan Implementation Guide
1.0.0-ballot - Comment only US

This page is part of the MCC eCare Plan Implementation Guide (v1.0.0-ballot: STU 1 Ballot 1) based on FHIR R4. . For a full list of available versions, see the Directory of published versions

Resource Profile: Document Reference to Patient's Personal Advance Care Plan (Advance Directive)

Official URL: http://hl7.org/fhir/us/mcc/StructureDefinition/DocRefPACP Version: 1.0.0-ballot
Active as of 2022-12-04 Computable Name: DocRefPACP

This profile constrains US Core DocumentReference to reference, query for and retrieve Personal Advance Care Plans that exist for a patient.

This profile constrains US Core DocumentReference to reference, query for and retrieve Personal Advance Care Plans that exist for a patient. In addition to the requirements set forth in US Core DocumentReference it constrains documentType codableConcept to the LOINC document code to 81334-5 “Patient Personal advance care plan”. The current FHIR specifications identifying a patient’s advance directives or a patient’s personal advance is immature and changing and unimplemented in systems. Therefore, at this time, the MCC eCare Plan seeks to find CDA based Personal Advance Care Plans that are comparatively widely implemented in systems and contain vital end of life patient requests and within which may point to actual Medical Order for Life-Sustaining Treatments (MOLST) or Physician Order for Life-Sustaining Treatments (POLST) .

No additional value sets were defined for use in this profile beyond the US Core Document Reference Profile.

Usage:

Formal Views of Profile Content

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

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... type 1..1CodeableConceptKind of document (LOINC if possible)
.... coding 1..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1codePatient Personal advance care plan
Fixed Value: 81334-5

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... 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
.... coding Σ1..*CodingCode defined by a terminology system
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code Σ1..1codePatient Personal advance care plan
Fixed Value: 81334-5
... Slices for category SΣ1..*CodeableConceptCategorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ0..*CodeableConceptCategorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... 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(US Core Practitioner Profile)Who and/or what authored the document
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
..... contentType SΣ0..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
..... data SC0..1base64BinaryData inline, base64ed
..... url SΣC0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)Context of the document content
.... period SΣ0..1PeriodTime of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... 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
... 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
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codePatient Personal advance care plan
Fixed Value: 81334-5
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... Slices for category SΣ1..*CodeableConceptCategorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ0..*CodeableConceptCategorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... 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(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..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 Σ0..1stringHuman-readable 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 SΣC1..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 SΣ0..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 SC0..1base64BinaryData inline, base64ed
..... url SΣC0..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

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

Mandatory: 2 elements
Must-Support: 1 element
Fixed Value: 2 elements

Extensions

This structure refers to these extensions:

Differential View

This structure is derived from USCoreDocumentReferenceProfile

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... type 1..1CodeableConceptKind of document (LOINC if possible)
.... coding 1..*CodingCode defined by a terminology system
..... system 0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code 1..1codePatient Personal advance care plan
Fixed Value: 81334-5

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... identifier SΣ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... 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
.... coding Σ1..*CodingCode defined by a terminology system
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... code Σ1..1codePatient Personal advance care plan
Fixed Value: 81334-5
... Slices for category SΣ1..*CodeableConceptCategorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ0..*CodeableConceptCategorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... 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(US Core Practitioner Profile)Who and/or what authored the document
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1AttachmentWhere to access the document
..... contentType SΣ0..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
..... data SC0..1base64BinaryData inline, base64ed
..... url SΣC0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)Context of the document content
.... period SΣ0..1PeriodTime of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
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-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*USCoreDocumentReferenceProfileA reference to a document
... 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
... 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
... resource-pertainsToGoal S0..*Reference(Goal)The resource-pertainsToGoal relates the resource to the goal(s) that pertain to it. Whenever there is a goal associated with a health concern or problem, this extension should be present and populated in activity (event or intent) resources.
URL: http://hl7.org/fhir/StructureDefinition/resource-pertainsToGoal
... 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
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ1..*CodingCode defined by a terminology system
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriIdentity of the terminology system
Fixed Value: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ1..1codePatient Personal advance care plan
Fixed Value: 81334-5
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... Slices for category SΣ1..*CodeableConceptCategorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:us-core SΣ0..*CodeableConceptCategorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a 'starter set' of categories supported for fetching and storing clinical notes.


... 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(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..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 Σ0..1stringHuman-readable 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 SΣC1..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 SΣ0..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 SC0..1base64BinaryData inline, base64ed
..... url SΣC0..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

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:us-corerequiredUSCoreDocumentReferenceCategory
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

This structure is derived from USCoreDocumentReferenceProfile

Summary

Mandatory: 2 elements
Must-Support: 1 element
Fixed Value: 2 elements

Extensions

This structure refers to these extensions:

 

Other representations of profile: CSV, Excel, Schematron