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 Tue Oct 27 14:11:48 UTC 2020 as a draft by ehealth.sundhed.dk.

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

This structure is derived from DocumentReference

Summary

Structures

This structure refers to these other structures:

This structure is derived from DocumentReference

Name	Card.	Type	Description & Constraints
DocumentReference	0..*	DocumentReference	A reference to a document
type	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (required)
class	0..1	CodeableConcept	Categorization of document Binding: Document Class (required)
subject	0..1	Reference(eHealth Patient \| eHealth Practitioner \| Group \| eHealth Device) {r }	Who/what is the subject of the document
author	0..*	Reference(eHealth Practitioner \| eHealth Organization \| eHealth Device \| eHealth Patient \| eHealth RelatedPerson) {r }	Who and/or what authored the document
authenticator	0..1	Reference(eHealth Practitioner \| eHealth Organization) {r }	Who/what authenticated the document
custodian	0..1	Reference(eHealth Organization) {r }	Organization which maintains the document
relatesTo
target	1..1	Reference(ehealth-documentreference)	Target of the relationship
content
format	0..1	Coding	Format/content rules for the document Binding: FormatCodes (required)
context
event	0..*	CodeableConcept	Main clinical acts documented Binding: Event Type Codes (required)
facilityType	0..1	CodeableConcept	Kind of facility where patient was seen Binding: Facility Type Codes (required)
practiceSetting	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: Practice Setting Codes (required)
sourcePatientInfo	0..1	Reference(eHealth Patient)	Patient demographics from source
Documentation for this format

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current \| superseded \| entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary \| final \| appended \| amended \| entered-in-error Binding: CompositionStatus (required)
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (required)
class	Σ	0..1	CodeableConcept	Categorization of document Binding: Document Class (required)
subject	Σ	0..1	Reference(eHealth Patient \| eHealth Practitioner \| Group \| eHealth Device) {r }	Who/what is the subject of the document
created	Σ	0..1	dateTime	Document creation time
indexed	Σ	1..1	instant	When this document reference was created
author	Σ	0..*	Reference(eHealth Practitioner \| eHealth Organization \| eHealth Device \| eHealth Patient \| eHealth RelatedPerson) {r }	Who and/or what authored the document
authenticator	Σ	0..1	Reference(eHealth Practitioner \| eHealth Organization) {r }	Who/what authenticated the document
custodian	Σ	0..1	Reference(eHealth Organization) {r }	Organization which maintains the document
relatesTo	?!Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	1..1	code	replaces \| transforms \| signs \| appends Binding: DocumentRelationshipType (required)
target	Σ	1..1	Reference(ehealth-documentreference)	Target of the relationship
description	Σ	0..1	string	Human-readable description (title)
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible)
content	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
attachment	Σ	1..1	Attachment	Where to access the document
format	Σ	0..1	Coding	Format/content rules for the document Binding: FormatCodes (required)
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
encounter	Σ	0..1	Reference(Encounter)	Context of the document content
event	Σ	0..*	CodeableConcept	Main clinical acts documented Binding: Event Type Codes (required)
period	Σ	0..1	Period	Time of service that is being documented
facilityType	Σ	0..1	CodeableConcept	Kind of facility where patient was seen Binding: Facility Type Codes (required)
practiceSetting	Σ	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: Practice Setting Codes (required)
sourcePatientInfo	Σ	0..1	Reference(eHealth Patient)	Patient demographics from source
related	Σ	0..*	BackboneElement	Related identifiers or resources
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Identifier of related objects or events
ref	Σ	0..1	Reference(Resource)	Related Resource
Documentation for this format

This structure is derived from DocumentReference

Summary

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DocumentReference

Name	Card.	Type	Description & Constraints
DocumentReference	0..*	DocumentReference	A reference to a document
type	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (required)
class	0..1	CodeableConcept	Categorization of document Binding: Document Class (required)
subject	0..1	Reference(eHealth Patient \| eHealth Practitioner \| Group \| eHealth Device) {r }	Who/what is the subject of the document
author	0..*	Reference(eHealth Practitioner \| eHealth Organization \| eHealth Device \| eHealth Patient \| eHealth RelatedPerson) {r }	Who and/or what authored the document
authenticator	0..1	Reference(eHealth Practitioner \| eHealth Organization) {r }	Who/what authenticated the document
custodian	0..1	Reference(eHealth Organization) {r }	Organization which maintains the document
relatesTo
target	1..1	Reference(ehealth-documentreference)	Target of the relationship
content
format	0..1	Coding	Format/content rules for the document Binding: FormatCodes (required)
context
event	0..*	CodeableConcept	Main clinical acts documented Binding: Event Type Codes (required)
facilityType	0..1	CodeableConcept	Kind of facility where patient was seen Binding: Facility Type Codes (required)
practiceSetting	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: Practice Setting Codes (required)
sourcePatientInfo	0..1	Reference(eHealth Patient)	Patient demographics from source
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current \| superseded \| entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary \| final \| appended \| amended \| entered-in-error Binding: CompositionStatus (required)
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (required)
class	Σ	0..1	CodeableConcept	Categorization of document Binding: Document Class (required)
subject	Σ	0..1	Reference(eHealth Patient \| eHealth Practitioner \| Group \| eHealth Device) {r }	Who/what is the subject of the document
created	Σ	0..1	dateTime	Document creation time
indexed	Σ	1..1	instant	When this document reference was created
author	Σ	0..*	Reference(eHealth Practitioner \| eHealth Organization \| eHealth Device \| eHealth Patient \| eHealth RelatedPerson) {r }	Who and/or what authored the document
authenticator	Σ	0..1	Reference(eHealth Practitioner \| eHealth Organization) {r }	Who/what authenticated the document
custodian	Σ	0..1	Reference(eHealth Organization) {r }	Organization which maintains the document
relatesTo	?!Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
code	Σ	1..1	code	replaces \| transforms \| signs \| appends Binding: DocumentRelationshipType (required)
target	Σ	1..1	Reference(ehealth-documentreference)	Target of the relationship
description	Σ	0..1	string	Human-readable description (title)
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible)
content	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
attachment	Σ	1..1	Attachment	Where to access the document
format	Σ	0..1	Coding	Format/content rules for the document Binding: FormatCodes (required)
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
encounter	Σ	0..1	Reference(Encounter)	Context of the document content
event	Σ	0..*	CodeableConcept	Main clinical acts documented Binding: Event Type Codes (required)
period	Σ	0..1	Period	Time of service that is being documented
facilityType	Σ	0..1	CodeableConcept	Kind of facility where patient was seen Binding: Facility Type Codes (required)
practiceSetting	Σ	0..1	CodeableConcept	Additional details about where the content was created (e.g. clinical specialty) Binding: Practice Setting Codes (required)
sourcePatientInfo	Σ	0..1	Reference(eHealth Patient)	Patient demographics from source
related	Σ	0..*	BackboneElement	Related identifiers or resources
id		0..1	string	xml:id (or equivalent in JSON)
extension		0..*	Extension	Additional Content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Identifier of related objects or events
ref	Σ	0..1	Reference(Resource)	Related Resource
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	extensible	Common Languages Max Binding: All Languages
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	required	DocumentType
DocumentReference.class	required	DocumentClass
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.format	required	FormatCodes
DocumentReference.context.event	required	EventTypeCodes
DocumentReference.context.facilityType	required	FacilityTypeCodes
DocumentReference.context.practiceSetting	required	PracticeSettingCodes

Constraints

Id	Path	Details	Requirements
dom-2	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-1	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty()
dom-4	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-3	DocumentReference	If 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-1	DocumentReference.relatesTo	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())
ele-1	DocumentReference.content	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())
ele-1	DocumentReference.context	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())
ele-1	DocumentReference.context.related	All FHIR elements must have a @value or children : hasValue() \| (children().count() > id.count())