eHealth Infrastructure (v2019.6)

StructureDefinition: ehealth-documentreference

Introduction

A DocumentReference resource is used to describe a document that is made available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be displayed to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type and that conforms to this definition.

Typically, DocumentReference resources are used in document indexing systems, such as IHE XDS , and are used to refer to:

  • CDA documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents , and even digital records of faxes where sufficient information is available
  • Other kinds of documents, such as records of prescriptions

Scope and Usage

In scope of the eHealth infrastructure the primary use of the DocumentReference resource is to contain or refer to information material used in relation to PlanDefinition and Questionnaire. This information material can be in the form of embedded material (of limited size) or references to videos, PDF-files or printed material.

See eHealth-plandefinition for further details.

Formal Views of Profile Content

The official URL for this profile is: 

http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-documentreference

This profile builds on DocumentReference.

This profile was published on Fri Nov 08 13:01:00 UTC 2019 as a draft by null.

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*A reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentType (required)
... class Σ0..1CodeableConceptCategorization of document
Binding: DocumentClass (required)
... subject Σ0..1Reference(eHealth Patient | eHealth Practitioner | Group | eHealth Device) {r}Who/what is the subject of the document
... created Σ0..1dateTimeDocument creation time
... indexed Σ1..1instantWhen this document reference was created
... author Σ0..*Reference(eHealth Practitioner | eHealth Organization | eHealth Device | eHealth Patient | eHealth RelatedPerson) {r}Who and/or what authored the document
... authenticator Σ0..1Reference(eHealth Practitioner | eHealth Organization) {r}Who/what authenticated the document
... custodian Σ0..1Reference(eHealth Organization) {r}Organization which maintains the document
... relatesTo ?!ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(ehealth-documentreference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content ΣI1..*BackboneElementDocument referenced
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... attachment Σ1..1AttachmentWhere to access the document
.... format Σ0..1CodingFormat/content rules for the document
Binding: FormatCodes (required)
... context ΣI0..1BackboneElementClinical context of document
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... encounter Σ0..1Reference(Encounter)Context of the document content
.... event Σ0..*CodeableConceptMain clinical acts documented
Binding: EventTypeCodes (required)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodes (required)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodes (required)
.... sourcePatientInfo Σ0..1Reference(eHealth Patient)Patient demographics from source
.... related ΣI0..*BackboneElementRelated identifiers or resources
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... identifier Σ0..1IdentifierIdentifier of related objects or events
..... ref Σ0..1Reference(Resource)Related Resource

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*A reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: Common Languages (extensible)
Max Binding: All Languages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional Content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | appended | amended | entered-in-error
Binding: CompositionStatus (required)
... type Σ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentType (required)
... class Σ0..1CodeableConceptCategorization of document
Binding: DocumentClass (required)
... subject Σ0..1Reference(eHealth Patient | eHealth Practitioner | Group | eHealth Device) {r}Who/what is the subject of the document
... created Σ0..1dateTimeDocument creation time
... indexed Σ1..1instantWhen this document reference was created
... author Σ0..*Reference(eHealth Practitioner | eHealth Organization | eHealth Device | eHealth Patient | eHealth RelatedPerson) {r}Who and/or what authored the document
... authenticator Σ0..1Reference(eHealth Practitioner | eHealth Organization) {r}Who/what authenticated the document
... custodian Σ0..1Reference(eHealth Organization) {r}Organization which maintains the document
... relatesTo ?!ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target Σ1..1Reference(ehealth-documentreference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content ΣI1..*BackboneElementDocument referenced
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... attachment Σ1..1AttachmentWhere to access the document
.... format Σ0..1CodingFormat/content rules for the document
Binding: FormatCodes (required)
... context ΣI0..1BackboneElementClinical context of document
.... id 0..1stringxml:id (or equivalent in JSON)
.... extension 0..*ExtensionAdditional Content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
.... encounter Σ0..1Reference(Encounter)Context of the document content
.... event Σ0..*CodeableConceptMain clinical acts documented
Binding: EventTypeCodes (required)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodes (required)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodes (required)
.... sourcePatientInfo Σ0..1Reference(eHealth Patient)Patient demographics from source
.... related ΣI0..*BackboneElementRelated identifiers or resources
..... id 0..1stringxml:id (or equivalent in JSON)
..... extension 0..*ExtensionAdditional Content defined by implementations
..... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored
..... identifier Σ0..1IdentifierIdentifier of related objects or events
..... ref Σ0..1Reference(Resource)Related Resource

doco Documentation for this format

 

Terminology Bindings

PathConformanceValueSet
DocumentReference.languageextensibleCommon Languages
Max Binding: All Languages
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredDocumentType
DocumentReference.classrequiredDocumentClass
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.formatrequiredFormatCodes
DocumentReference.context.eventrequiredEventTypeCodes
DocumentReference.context.facilityTyperequiredFacilityTypeCodes
DocumentReference.context.practiceSettingrequiredPracticeSettingCodes

Constraints

IdPathDetailsRequirements
dom-2DocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-1DocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain any narrative
: contained.text.empty()
dom-4DocumentReferenceIf 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-3DocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
: contained.where(('#'+id in %resource.descendants().reference).not()).empty()
ele-1DocumentReference.relatesToAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1DocumentReference.contentAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1DocumentReference.contextAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
ele-1DocumentReference.context.relatedAll FHIR elements must have a @value or children
: hasValue() | (children().count() > id.count())
.