Interweave Implementation Guide
0.1.0 - ci-build
Interweave Implementation Guide - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the STU3 profiles here.
Official URL: https://fhir.interweavedigital.nhs.uk/R4/StructureDefinition/Interweave-DocumentReference | Version: 0.0.1 | |||
Draft as of 2024-07-15 | Computable Name: InterweaveDocumentReference |
Interweave DocumentReference resource profile - DRAFT.
Status: DRAFT: For Review
This profile sets minimum expectations for the DocumentReference resource. We use the DocumentReference structure definition as a base to this profile.
The following mandatory fields are defined in order to properly describe a DocumentReference:
Type - essential information to help categorise the type of document.
The categorisation of document types is a much debated topic, with a number of alternative standards still vying for precedence. However for practical purposes of consistency a regional design decision has been made based on the SNOMED refset 24501000000105: EHR composition types. This is therefore specified as "preferred" and we ask that SNOMED coding based on this list is provided.
Data Providers and Data Consumers SHOULD support the following contentTypes:
- application/pdf
- text/html
- image/jpeg
- image/png (currently not supported in Interweave Portal, however it is on the roadmap)
(This list may be added to by request and discussion)
Other contentTypes should only be used with caution, as not all Data Consumers may be able to view them.
In addition the following fields are "Must Support" - ie they must be populated if relevant and known:
Other fields are optional and may be populated if known - on the understanding that not all data consumers will necessarily make use of them. Points of note include:
The DocumentReference this offers three different ways to transmit the document content and it is important to understand the details of this. The sections below cover each option in turn.
(1) Embedded document (only supported for messaging NOT online query)
This is the “simplest” approach, as the document content is embedded directly into the DocumentReference. Note that the contentType (mime-type) is provided so that the consumer is able to judge whether it has the ability to display this format of document eg PDF, etc. (This is the same for all three approaches).
For example the “content” section of a DocumentReference would look like:
"content": [{ "attachment": { "contentType": "text/html", "data":"PGRpdiB4123ucz0iaHR0cDovL123dy53My5vcmcvMTk5OS94aHRtbCI ... etc..." } }]
This embedded approach is often suitable for messaging, where a relevant document is being specifically sent (eg Ambulance Transfer of Care). However for online query it has the significant disadvantage of making the DocumentReference resources very large - as the whole document is transferred even when just viewing the list of documents available. Typically there may be many documents about a patient, but only one or two which are relevant for the user to actually view. It is very inefficient (and slow) to transfer the entirety of the documents when a user is only perusing the list.
(NB: Despite this limitation, GP Connect is an important use-case which returns embedded document content. However GP Connect documents are not returned from ordinary online queries and instead must be specifically requested from a screen developed to meet NHSD accreditation requirements. The reason for embedding is that, having requested a patient’s GP Record, it is almost always going to be desired to view the document content).
(2) Linked document (recommended)
This replaces the content in the DocumentReference with a link. For example:
"content": [{ "attachment": { "contentType": "text/html", "url": "https://my.server.com/documents/21f51e78-a46d-402c-aa22-dd43e0fec530" } }]
This is clearly much more efficient. This list of DocumentReferences contains only metadata about the documents, and if the user wants to open the document then it is a case of following the link to download it. This performs a simple binary download of the document bytes – as would be provided by hosting the document on any standard web server.
Note that InterWeave Connect offers a proxy service to avoid the need for point-to-point networking for document downloads. Instead the urls in the DocumentReference are automatically rewritten to point at a central hub which in turn connects to the Data Provider and streams document downloads.
(3) FHIR Binary Resource (only recommended if implemented comprehensively)
Yet another possible approach is to replace the content in the DocumentReference with a link to a FHIR Binary Resource http://hl7.org/fhir/stu3/binary.html. This is similar in principle to the Linked document approach, but adds an extra layer of wrappings and complexity to the Data Provider's implementation. For that reason it is not recommended unless a Data Provider is working with a local system which already exposes documents in this way. Note: that the contentType of the document reference must be the mime type of the document encoded by the binary resource (see GET behaviour below)
The “content” section of a DocumentReference with a linked Binary Resource would now look like this:
"content": [{ "attachment": { "contentType": "text/html", "url": "https://my.server.com/fhirpath/Binary/21f51e78-a46d-402c-aa22-dd43e0fec530" } }]
When the link is followed then it again returns the binary content – as would be provided by hosting the document on any standard web server.
(This is because of a feature of the FHIR specification that treats Binary resources differently from any other resource. When a FHIR server receives a GET request for a Binary resource then it MUST return the binary document content rather than the Binary resource. However the FHIR specification also requires that this behaviour can be overridden by a consumer by inserting the HTTP Accept header with value “application/fhir+json” (or even “application/fhir+xml”). This then returns a more complete FHIR data structure with the document content embedded – although for document viewing purposes it is difficult to envisage why a consumer would desire this)
Summary of Requirements for DocumentReference content
Data Providers SHOULD use the “linked document” mechanism when publishing documents for on-demand retrieval
This is (2) above, which is recommended as a simple and efficient approach.
Data Providers MUST NOT embed documents for on-demand retrieval, as this is inefficient
Data Providers MAY publish documents as FHIR Binary Resources. This is equivalent from a Data Consumer perspective as it provides a link to follow to download the document. However it is not recommended due to the additional complexity for a Data Provider. If this option is chosen then the Data Provider MUST fully support the FHIR specification.
Data Consumers MUST support viewing of documents via a DocumentReference resource which contains a link for downloading the actual document content
Data Consumers MAY leave the HTTP “Accept” header blank, and SHOULD NOT populate it with anything other than the mime-type advertised by the Data Provider in the DocumentReference
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
masterIdentifier | ||||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
Slices for identifier | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | |
identifier:All Slices | Content/Rules for all slices | |||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
identifier:localIdentifier | S | 0..1 | Identifier | Other identifiers for the document |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier |
value | S | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
status | S | 1..1 | code | current | superseded | entered-in-error |
docStatus | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
category | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
subject | S | 1..1 | Reference(InterweavePatient) | Who is the subject of the document |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
date | S | 1..1 | instant | When this document reference was created |
author | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |
relatesTo | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | |
description | 0..1 | string | Human-readable description (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | |
securityLabel | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers | |
content | S | 1..* | BackboneElement | Document referenced |
attachment | S | 1..1 | Attachment | Where to access the document |
contentType | S | 1..1 | code | Mime type of the content, with charset etc. |
creation | S | 0..1 | dateTime | Date attachment was first created |
context | ||||
encounter | S | 0..* | Reference(InterweaveEncounter) | Context of the document content |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
period | S | 0..1 | Period | Time of service that is being documented |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: UK Core Care Setting Type (preferred) | |
sourcePatientInfo | 0..0 | |||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | |
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Other identifiers for the document | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier | ||||
value | SΣ | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) | ||||
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who is the subject of the document | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
date | SΣ | 1..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |||||
relatesTo | Σ | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | ||||
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 (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | ||||
securityLabel | Σ | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣ | 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 | ||||
creation | SΣ | 0..1 | dateTime | Date attachment was first created | ||||
context | Σ | 0..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | S | 0..* | Reference(InterweaveEncounter) | Context of the document content | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: UK Core Care Setting Type (preferred) | |||||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | ||||
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
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() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
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 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
Slices for identifier | Σ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Other identifiers for 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 | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier | ||||
value | SΣ | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) | ||||
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 | 0..* | 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 | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | ||||
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 | 0..* | 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 | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who is the subject of 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 | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
date | SΣ | 1..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |||||
relatesTo | Σ | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | ||||
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 (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | ||||
securityLabel | Σ | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers 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 | SΣ | 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 | 0..1 | base64Binary | Data inline, base64ed | |||||
url | Σ | 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 | SΣ | 0..1 | dateTime | Date attachment was first created | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
context | Σ | 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..* | Reference(InterweaveEncounter) | Context of the document content | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
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: UK Core Care Setting Type (preferred) | |||||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.masterIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.masterIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | ||||
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
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() |
This structure is derived from DocumentReference
Summary
Mandatory: 7 elements(17 nested mandatory elements)
Must-Support: 25 elements
Fixed: 3 elements
Prohibited: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | S | 0..1 | id | Logical id of this artifact |
meta | ||||
id | 0..0 | |||
versionId | S | 0..1 | id | Version specific identifier |
lastUpdated | S | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. |
profile | S | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. |
security | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers | |
Slices for tag | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system | |
tag:Source | S | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | |
version | 0..0 | |||
code | S | 1..1 | code | The Data Provider Id of the system supplying the data |
display | S | 1..1 | string | Name of the system supplying the data |
tag:Provenance | S | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data |
id | 0..0 | |||
system | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | |
version | 0..0 | |||
code | S | 1..1 | code | The ODS Code of the organisation responsible for the data |
display | S | 1..1 | string | Name of the organisation supplying the data |
implicitRules | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | |
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) | |
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |
masterIdentifier | ||||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
Slices for identifier | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | |
identifier:All Slices | Content/Rules for all slices | |||
assigner | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | |
identifier:localIdentifier | S | 0..1 | Identifier | Other identifiers for the document |
system | S | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier |
value | S | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique |
period | 0..0 | |||
status | S | 1..1 | code | current | superseded | entered-in-error |
docStatus | S | 1..1 | code | preliminary | final | amended | entered-in-error |
type | S | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
category | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | |
coding | ||||
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
display | 1..1 | string | Representation defined by the system | |
subject | S | 1..1 | Reference(InterweavePatient) | Who is the subject of the document |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
date | S | 1..1 | instant | When this document reference was created |
author | S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 1..1 | string | Description of the referenced resource | |
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |
relatesTo | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | |
description | 0..1 | string | Human-readable description (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | |
securityLabel | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers | |
content | S | 1..* | BackboneElement | Document referenced |
attachment | S | 1..1 | Attachment | Where to access the document |
contentType | S | 1..1 | code | Mime type of the content, with charset etc. |
creation | S | 0..1 | dateTime | Date attachment was first created |
context | ||||
encounter | S | 0..* | Reference(InterweaveEncounter) | Context of the document content |
reference | 1..1 | string | Reference to a resource (could be Contained) | |
identifier | 0..1 | Identifier | If relevant could include an id | |
display | 0..1 | string | If relevant, description of the referenced resource | |
period | S | 0..1 | Period | Time of service that is being documented |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: UK Core Care Setting Type (preferred) | |
sourcePatientInfo | 0..0 | |||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | |
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
Slices for identifier | Σ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Other identifiers for the document | ||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier | ||||
value | SΣ | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) | ||||
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who is the subject of the document | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
date | SΣ | 1..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |||||
relatesTo | Σ | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | ||||
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 (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | ||||
securityLabel | Σ | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
content | SΣ | 1..* | BackboneElement | Document referenced | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
attachment | SΣ | 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 | ||||
creation | SΣ | 0..1 | dateTime | Date attachment was first created | ||||
context | Σ | 0..1 | BackboneElement | Clinical context of document | ||||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
encounter | S | 0..* | Reference(InterweaveEncounter) | Context of the document content | ||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: UK Core Care Setting Type (preferred) | |||||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | ||||
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
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() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | SΣ | 0..1 | id | Version specific identifier | ||||
lastUpdated | SΣ | 0..1 | instant | MANDATORY except in Contained Resources. When the resource version last changed. | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
profile | SΣ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to. Should list (i) this profile (ii) base profile for this resource. | ||||
security | Σ | 0..* | Coding | DISCOURAGED - may not be honoured by Data Consumers Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for tag | Σ | 0..* | Coding | Tags applied to this resource Slice: Unordered, Open by value:system Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
tag:Source | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The Data Provider Id (and display text) of the system supplying the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Source | ||||
code | SΣ | 1..1 | code | The Data Provider Id of the system supplying the data | ||||
display | SΣ | 1..1 | string | Name of the system supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
tag:Provenance | SΣ | 0..1 | Coding | MANDATORY except in Contained Resources. The ODS Code (and display text) of the organisation responsible for the data Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Fixed Value: https://fhir.interweavedigital.nhs.uk/Provenance | ||||
code | SΣ | 1..1 | code | The ODS Code of the organisation responsible for the data | ||||
display | SΣ | 1..1 | string | Name of the organisation supplying the data | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
implicitRules | ?!Σ | 0..1 | uri | DISCOURAGED - may not be honoured by Data Consumers | ||||
language | 0..1 | code | English is assumed (not currently a multi-lingual implementation) Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | DISCOURAGED - the preferred approach is to offer structured data fields which a Data Consumer can then render and present in a manner most suited to its users | |||||
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 | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
Slices for identifier | Σ | 0..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:system | ||||
identifier:All Slices | Content/Rules for all slices | |||||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient | ||||
value | Σ | 0..1 | string | The value that is unique Example General: 123456 | ||||
period | Σ | 0..1 | Period | Time period when id is/was valid for use | ||||
assigner | Σ | 0..1 | Reference(InterweaveOrganization) | Organization that issued id (may be just text) | ||||
identifier:localIdentifier | SΣ | 0..1 | Identifier | Other identifiers for 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 | |||||
use | ?!Σ | 0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | ||||
type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. | ||||
system | SΣ | 1..1 | uri | The namespace for the identifier value Fixed Value: https://fhir.interweavedigital.nhs.uk/Id/local-documentreference-identifier | ||||
value | SΣ | 1..1 | string | The Local documentreference Identifier. Please prefix with ODS code plus period (XXX.) to ensure unique Example General: 123456 | ||||
assigner | Σ | 0..1 | Reference(Organization) | Organization that issued id (may be just text) | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | SΣ | 1..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Type of document Binding: InterweaveDocumentType (preferred) | ||||
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 | 0..* | 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 | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (preferred) | ||||
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 | 0..* | 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 | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 1..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 | ||||
subject | SΣ | 1..1 | Reference(InterweavePatient) | Who is the subject of 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 | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
date | SΣ | 1..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document. NB: For most use-cases this should contain a single practitioner who is the main contact for any further questions | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 1..1 | string | Description of the referenced resource | ||||
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
custodian | 0..1 | Reference(Organization) | DISCOURAGED - this information is already covered by the provenance tags | |||||
relatesTo | Σ | 0..* | BackboneElement | DISCOURAGED - use with great caution as consumer systems are likely to display a simple list of documents, and may not interpret these relationships | ||||
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 (title). Useful to populate, but acceptable to omit if nothing to add over-and-above the 'type' | ||||
securityLabel | Σ | 0..* | CodeableConcept | DISCOURAGED - unlikely to be honoured by consumers 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 | SΣ | 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 | 0..1 | base64Binary | Data inline, base64ed | |||||
url | Σ | 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 | SΣ | 0..1 | dateTime | Date attachment was first created | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
context | Σ | 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..* | Reference(InterweaveEncounter) | Context of the document content | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
reference | ΣC | 1..1 | string | Reference to a resource (could be Contained) | ||||
type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
identifier | Σ | 0..1 | Identifier | If relevant could include an id | ||||
display | Σ | 0..1 | string | If relevant, description of the referenced resource | ||||
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: UK Core Care Setting Type (preferred) | |||||
related | 0..* | Reference(Resource) | DISCOURAGED - see above for linkage to Encounter. Other linkages may be defined in future only if use-cases arise | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Source | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.meta.tag:Provenance | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.masterIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.masterIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.identifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.use | required | IdentifierUsehttp://hl7.org/fhir/ValueSet/identifier-use|4.0.1 from the FHIR Standard | ||||
DocumentReference.identifier:localIdentifier.type | extensible | Identifier Type Codeshttp://hl7.org/fhir/ValueSet/identifier-type from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | InterweaveDocumentTypehttps://fhir.interweavedigital.nhs.uk/R4/ValueSet/Interweave-DocumentType from this IG | ||||
DocumentReference.category | preferred | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.encounter.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | preferred | UKCoreCareSettingTypehttps://fhir.hl7.org.uk/ValueSet/UKCore-CareSettingType from this IG |
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() |
This structure is derived from DocumentReference
Summary
Mandatory: 7 elements(17 nested mandatory elements)
Must-Support: 25 elements
Fixed: 3 elements
Prohibited: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
Element name | Change details |
---|---|
identifier:localIdentifier.system |
|
type |
|
category |
|
date |
|
created |
|
author |
|
authenticator |
|
context.encounter |
|
context.practiceSetting |
|