This page is part of the PACIO Advance Directive Information Implementation Guide (v1.0.0: STU 1) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Official URL: http://hl7.org/fhir/us/pacio-adi/StructureDefinition/ADI-DocumentReference | Version: 1.0.0 | |||
Active as of 2024-01-11 | Computable Name: ADIDocumentReference |
This profile defines constraints that represent the information needed to register an advance directive information document on a FHIR server.
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 | |
type | 1..1 | CodeableConcept | Advance Directive Categories | |
category | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | |
subject | 1..1 | Reference(US Core Patient Profile) | Patient | |
author | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document | |
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
Documentation for this format |
Path | Conformance | ValueSet |
DocumentReference.category | extensible | USCoreDocumentReferenceCategory |
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 | ||||
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status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||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 | Advance Directive Categories Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Patient | ||||
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 | ||||
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains 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 | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
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 | extensible | 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 ) |
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 | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
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 | Advance Directive Categories Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Patient | ||||
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) | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document | ||||
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 | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
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 | extensible | 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 |
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 | |
type | 1..1 | CodeableConcept | Advance Directive Categories | |
category | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | |
subject | 1..1 | Reference(US Core Patient Profile) | Patient | |
author | 0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile) | Who and/or what authored the document | |
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document |
Documentation for this format |
Path | Conformance | ValueSet |
DocumentReference.category | extensible | USCoreDocumentReferenceCategory |
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 | ||||
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 | Advance Directive Categories Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Patient | ||||
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 | ||||
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains 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 | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
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 | extensible | 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 ) |
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 | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
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 | Advance Directive Categories Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: US Core DocumentReference Category (extensible) | ||||
subject | SΣ | 1..1 | Reference(US Core Patient Profile) | Patient | ||||
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) | Who and/or what authored the document | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
custodian | S | 0..1 | Reference(US Core Organization Profile) | Organization which maintains the document | ||||
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 | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
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 | extensible | 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 |
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron