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
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:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from USCoreDocumentReferenceProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainsToGoal | S | 0..* | 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..1 | CodeableConcept | Kind of document (LOINC if possible) | |
coding | 1..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainsToGoal | S | 0..* | 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
type | 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'
| ||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
code | Σ | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | ||||
Slices for category | 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. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Categorization 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 | 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 | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who and/or what authored the document | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | Where to access the document | ||||
contentType | 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 | ||||
data | 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 | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!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 | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DocumentReference.status | required | DocumentReferenceStatus | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
| ||||
DocumentReference.category | example | DocumentClassValueSet | ||||
DocumentReference.category:us-core | required | USCoreDocumentReferenceCategory | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 ) | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem ) |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
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 | ||||
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 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainsToGoal | S | 0..* | 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..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..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) | ||||
docStatus | 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: 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'
| ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
Slices for category | 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. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Categorization 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 | 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 | ||||
author | 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 | |||||
custodian | 0..1 | Reference(Organization) | Organization which maintains the document | |||||
relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!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. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
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. | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | Where to access the document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | 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 | ||||
data | 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 | ||||
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 | ||||
creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!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 | ||||
event | 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 | ||||
facilityType | 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). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DocumentReference.language | preferred | CommonLanguages
| ||||
DocumentReference.status | required | DocumentReferenceStatus | ||||
DocumentReference.docStatus | required | CompositionStatus | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
| ||||
DocumentReference.category | example | DocumentClassValueSet | ||||
DocumentReference.category:us-core | required | USCoreDocumentReferenceCategory | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipType | ||||
DocumentReference.securityLabel | extensible | All Security Labels | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 ) | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
| ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem ) | ||||
DocumentReference.context.event | example | ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from USCoreDocumentReferenceProfile
Differential View
This structure is derived from USCoreDocumentReferenceProfile
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
resource-pertainsToGoal | S | 0..* | 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..1 | CodeableConcept | Kind of document (LOINC if possible) | |
coding | 1..* | Coding | Code defined by a terminology system | |
system | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | |
code | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainsToGoal | S | 0..* | 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..* | Extension | Extensions that cannot be ignored | ||||
identifier | SΣ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
type | 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'
| ||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
code | Σ | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | ||||
Slices for category | 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. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Categorization 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 | 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 | ||||
author | SΣ | 0..* | Reference(US Core Practitioner Profile) | Who and/or what authored the document | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | Where to access the document | ||||
contentType | 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 | ||||
data | 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 | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!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 | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DocumentReference.status | required | DocumentReferenceStatus | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
| ||||
DocumentReference.category | example | DocumentClassValueSet | ||||
DocumentReference.category:us-core | required | USCoreDocumentReferenceCategory | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 ) | ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem ) |
Id | Grade | Path(s) | Details | Requirements |
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
dom-3 | error | DocumentReference | If 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-4 | error | DocumentReference | If 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-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | USCoreDocumentReferenceProfile | A reference to a document | |||||
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 | ||||
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 | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
resource-pertainsToGoal | S | 0..* | 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..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..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) | ||||
docStatus | 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: 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'
| ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
coding | Σ | 1..* | Coding | Code defined by a terminology system | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 0..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Patient Personal advance care plan Fixed Value: 81334-5 | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
Slices for category | 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. | ||||
category:us-core | SΣ | 0..* | CodeableConcept | Categorization 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 | 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 | ||||
author | 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 | |||||
custodian | 0..1 | Reference(Organization) | Organization which maintains the document | |||||
relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!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. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
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. | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣC | 1..1 | Attachment | Where to access the document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
contentType | 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 | ||||
data | 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 | ||||
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 | ||||
creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
format | SΣ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | ||||
context | SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?!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 | ||||
event | 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 | ||||
facilityType | 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). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
DocumentReference.language | preferred | CommonLanguages
| ||||
DocumentReference.status | required | DocumentReferenceStatus | ||||
DocumentReference.docStatus | required | CompositionStatus | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
| ||||
DocumentReference.category | example | DocumentClassValueSet | ||||
DocumentReference.category:us-core | required | USCoreDocumentReferenceCategory | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipType | ||||
DocumentReference.securityLabel | extensible | All Security Labels | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 ) | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
| ||||
DocumentReference.content.format | extensible | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem ) | ||||
DocumentReference.context.event | example | ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet |
Id | Grade | Path(s) | Details | Requirements |
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron