haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG)
1.0.0 - ci-build
haau3 FHIR Implementation Guide (HFIG) - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://haau3.com/fhir/StructureDefinition/haau3-document-reference | Version: 1.0.0 | |||
| Draft as of 2026-10-14 | Computable Name: Haau3DocumentReference | |||
A clinical document or note about a care recipient. The document's content is delivered as an address naming a file held on the same server, and haau3 delivers that file with it; a document commonly carries several renderings of one note, one per attachment.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  | ||||
|---|---|---|---|---|---|---|---|---|
  DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |||||
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
 identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |||||
| status |
1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | |||||
| type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| |||||
  Slices for category |
1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
   category:uscore |
0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | |||||
 subject |
1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | |||||
| date |
0..1 | instant | (USCDI) When this document reference was created | |||||
| author |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | (USCDI) Who and/or what authored the document | |||||
| content |
1..* | BackboneElement | (USCDI) Document referenced | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
C | 1..1 | Attachment | (USCDI) Where to access the document Constraints: us-core-6 | ||||
| contentType |
0..1 | code | (USCDI) 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 |
C | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
 url |
C | 1..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| format |
0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | |||||
 context |
0..1 | BackboneElement | (USCDI) Clinical context of document | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | (USCDI) Context of the document content | |||||
| period |
0..1 | Period | (USCDI) Time of service that is being documented | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | US Core DocumentReference Type | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
This structure is derived from USCoreDocumentReferenceProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |
 identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |
| content |
||||
| attachment |
||||
| url |
1..1 | url | (USCDI) Uri where the data can be found | |
| Documentation for this format | ||||
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| masterIdentifier |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |||||
| status |
1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| |||||
| Slices for category |
1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| category:uscore |
0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | |||||
| subject |
1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | |||||
| date |
0..1 | instant | (USCDI) When this document reference was created | |||||
| author |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | (USCDI) Who and/or what authored the document | |||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
1..* | BackboneElement | (USCDI) Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
C | 1..1 | Attachment | (USCDI) Where to access the document Constraints: us-core-6 | ||||
| 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 |
0..1 | code | (USCDI) 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 |
0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | |||||
| data |
C | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
| url |
C | 1..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
0..1 | unsignedInt | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
0..1 | dateTime | Date attachment was first created | |||||
| format |
0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | |||||
| context |
0..1 | BackboneElement | (USCDI) Clinical context of document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | (USCDI) 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 |
0..1 | Period | (USCDI) 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 | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | US Core DocumentReference Type | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.4 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
This structure is derived from USCoreDocumentReferenceProfile
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |||||
| status |
1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | |||||
| type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| |||||
| Slices for category |
1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| category:uscore |
0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | |||||
| subject |
1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | |||||
| date |
0..1 | instant | (USCDI) When this document reference was created | |||||
| author |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | (USCDI) Who and/or what authored the document | |||||
| content |
1..* | BackboneElement | (USCDI) Document referenced | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
C | 1..1 | Attachment | (USCDI) Where to access the document Constraints: us-core-6 | ||||
| contentType |
0..1 | code | (USCDI) 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 |
C | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
| url |
C | 1..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| format |
0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | |||||
| context |
0..1 | BackboneElement | (USCDI) Clinical context of document | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | (USCDI) Context of the document content | |||||
| period |
0..1 | Period | (USCDI) Time of service that is being documented | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | US Core DocumentReference Type | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
Differential View
This structure is derived from USCoreDocumentReferenceProfile
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |
| identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |
| content |
||||
| attachment |
||||
| url |
1..1 | url | (USCDI) Uri where the data can be found | |
| Documentation for this format | ||||
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | USCoreDocumentReferenceProfile(6.1.0) | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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 This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| masterIdentifier |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
1..* | Identifier | (USCDI) Other identifiers for the document | |||||
| status |
1..1 | code | (USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
1..1 | CodeableConcept | (USCDI) Kind of document (LOINC if possible) Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'
| |||||
| Slices for category |
1..* | CodeableConcept | (USCDI) Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them | |||||
| category:uscore |
0..* | CodeableConcept | (USCDI) Categorization of document Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets | |||||
| subject |
1..1 | Reference(US Core Patient Profile) | (USCDI) Who/what is the subject of the document | |||||
| date |
0..1 | instant | (USCDI) When this document reference was created | |||||
| author |
0..* | Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) | (USCDI) Who and/or what authored the document | |||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
1..* | BackboneElement | (USCDI) Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
C | 1..1 | Attachment | (USCDI) Where to access the document Constraints: us-core-6 | ||||
| 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 |
0..1 | code | (USCDI) 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 |
0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | |||||
| data |
C | 0..1 | base64Binary | (USCDI) Data inline, base64ed | ||||
| url |
C | 1..1 | url | (USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
0..1 | unsignedInt | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
0..1 | dateTime | Date attachment was first created | |||||
| format |
0..1 | Coding | (USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible) | |||||
| context |
0..1 | BackboneElement | (USCDI) Clinical context of document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(US Core Encounter Profile) | (USCDI) 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 |
0..1 | Period | (USCDI) 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 | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📦4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | US Core DocumentReference Type | 📦6.1.0 | US Core v6.1 |
| DocumentReference.category | Base | example | Document Class Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.category:uscore | Base | required | US Core DocumentReference Category | 📦6.1.0 | US Core v6.1 |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | preferred | Common Languages | 📦4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | extensible | DocumentReference Format Code Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.4 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📦4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📦4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
| us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. |
url.exists() or data.exists()
|
This structure is derived from USCoreDocumentReferenceProfile
Other representations of profile: CSV, Excel, Schematron