US Veterans Health Administration FHIR Map Set Implementation Guide
1.10.0 - 251101 United States of America flag

US Veterans Health Administration FHIR Map Set Implementation Guide - Downloaded Version 1.10.0 See the Directory of published versions

Resource Profile: Document Reference DocumentReference

Official URL: http://va.gov/fhir/StructureDefinition/DocumentReferenceDocumentReference Version: 1.10.0
Active as of 2025-11-04 Computable Name: DocumentReferenceDocumentReference

This StructureDefinition contains the maps for VistA file TIU DOCUMENT (8925) to us-core-documentreference.

​See also the FHIR Shorthand.

Use Case Overview

Use Case: Document Reference«us-core-documentreference»DocumentReferenceDocumentReferencesubjectauthorauthenticatorcustodian«FHIR Binary»DocumentReferenceBinaryPatientPractitionerPractitionerPractitionerOrganization

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
.... 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 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
Required Pattern: current
... docStatus SΣC 0..1 code preliminary | final | amended | entered-in-error
Binding: documentReferencedocStatus FHIR (required): see mapping VF_documentReferencedocStatus
Constraints: drdr-34-1787, drdr-34-1788, drdr-34-1789
... type SΣ 1..1 CodeableConcept 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'
Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc SΣ 0..1 Coding Code defined by a terminology system
...... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code SΣ 0..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:us-core SΣ 0..* CodeableConcept 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.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo Σ 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo:All Slices Content/Rules for all slices
..... 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
.... relatesTo:va-parent SΣ 0..1 BackboneElement Relationships to other documents
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-882-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent SΣ 0..1 BackboneElement Relationships to other documents
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-884-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description SΣ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: us-core-6
..... id S 0..1 string Unique id for inter-element referencing
..... contentType SΣ 0..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.
Required Pattern: text/plain
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash SΣ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 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 SΣ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 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
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG
DocumentReference.type Base required US Core DocumentReference Type 📦7.0.0 US Core v7.0
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category:us-core Base required US Core DocumentReference Category 📦7.0.0 US Core v7.0
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-parent.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-id-parent.​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 v6.5
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.

Constraints

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()
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... masterIdentifier 0..1 Identifier Master Version Specific Identifier
... identifier 0..* Identifier Other identifiers for the document
.... system S 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
... status 1..1 code current | superseded | entered-in-error
Required Pattern: current
... type 1..1 CodeableConcept Kind of document (LOINC if possible)
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc S 0..1 Coding Code defined by a terminology system
...... system S 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code S 0..1 code Symbol in syntax defined by the system
.... text S 0..1 string Plain text representation of the concept
... Slices for category Content/Rules for all slices
.... category:us-core 0..* CodeableConcept Categorization of document
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
... subject 1..1 Reference(Patient) Who/what is the subject of the document
... date 0..1 instant When this document reference was created
... author 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo:va-parent S 0..1 BackboneElement Relationships to other documents
..... code SC 1..1 code replaces | transforms | signs | appends
Constraints: drdr-34-882-1
..... target SC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent S 0..1 BackboneElement Relationships to other documents
..... code SC 1..1 code replaces | transforms | signs | appends
Constraints: drdr-34-884-1
..... target SC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description S 0..1 string Human-readable description
... securityLabel 0..* CodeableConcept Document security-tags
... content
.... id 0..1 string Unique id for inter-element referencing
.... attachment
..... id S 0..1 string Unique id for inter-element referencing
..... contentType 0..1 code Mime type of the content, with charset etc.
Required Pattern: text/plain
..... language 0..1 code Human language of the content (BCP-47)
..... url 0..1 url Uri where the data can be found
..... size S 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash S 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title S 0..1 string Label to display in place of the data
..... creation S 0..1 dateTime Date attachment was first created
.... format 0..1 Coding Format/content rules for the document
... context
.... id 0..1 string Unique id for inter-element referencing
.... encounter 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 0..* CodeableConcept Main clinical acts documented
.... period
..... start S 0..1 dateTime Starting time with inclusive boundary
..... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
.... practiceSetting S 0..1 CodeableConcept 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG

Constraints

Id Grade Path(s) Description Expression
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... 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
... 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 Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* 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 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
.... 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(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
Required Pattern: current
... docStatus SΣC 0..1 code preliminary | final | amended | entered-in-error
Binding: documentReferencedocStatus FHIR (required): see mapping VF_documentReferencedocStatus
Constraints: drdr-34-1787, drdr-34-1788, drdr-34-1789
... type SΣ 1..1 CodeableConcept 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'
Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:us-core SΣ 0..* CodeableConcept 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.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo Σ 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo: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
..... 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
.... relatesTo:va-parent SΣ 0..1 BackboneElement Relationships to other documents
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-882-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent SΣ 0..1 BackboneElement Relationships to other documents
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-884-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description SΣ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: us-core-6
..... id S 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 0..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.
Required Pattern: text/plain
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash SΣ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 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 SΣ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG
DocumentReference.type Base required US Core DocumentReference Type 📦7.0.0 US Core v7.0
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category:us-core Base required US Core DocumentReference Category 📦7.0.0 US Core v7.0
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-parent.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-id-parent.​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 v6.5
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.

Constraints

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()
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true
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

Summary

Must-Support: 25 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DocumentReference.type.coding
  • The element 1 is sliced based on the value of DocumentReference.relatesTo

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
.... 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 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
Required Pattern: current
... docStatus SΣC 0..1 code preliminary | final | amended | entered-in-error
Binding: documentReferencedocStatus FHIR (required): see mapping VF_documentReferencedocStatus
Constraints: drdr-34-1787, drdr-34-1788, drdr-34-1789
... type SΣ 1..1 CodeableConcept 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'
Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc SΣ 0..1 Coding Code defined by a terminology system
...... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code SΣ 0..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:us-core SΣ 0..* CodeableConcept 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.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo Σ 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo:All Slices Content/Rules for all slices
..... 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
.... relatesTo:va-parent SΣ 0..1 BackboneElement Relationships to other documents
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-882-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent SΣ 0..1 BackboneElement Relationships to other documents
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-884-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description SΣ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: us-core-6
..... id S 0..1 string Unique id for inter-element referencing
..... contentType SΣ 0..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.
Required Pattern: text/plain
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash SΣ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 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 SΣ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 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
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG
DocumentReference.type Base required US Core DocumentReference Type 📦7.0.0 US Core v7.0
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category:us-core Base required US Core DocumentReference Category 📦7.0.0 US Core v7.0
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-parent.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-id-parent.​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 v6.5
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.

Constraints

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()
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true
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

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... masterIdentifier 0..1 Identifier Master Version Specific Identifier
... identifier 0..* Identifier Other identifiers for the document
.... system S 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
... status 1..1 code current | superseded | entered-in-error
Required Pattern: current
... type 1..1 CodeableConcept Kind of document (LOINC if possible)
.... Slices for coding 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc S 0..1 Coding Code defined by a terminology system
...... system S 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... code S 0..1 code Symbol in syntax defined by the system
.... text S 0..1 string Plain text representation of the concept
... Slices for category Content/Rules for all slices
.... category:us-core 0..* CodeableConcept Categorization of document
Required Pattern: At least the following
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
... subject 1..1 Reference(Patient) Who/what is the subject of the document
... date 0..1 instant When this document reference was created
... author 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo:va-parent S 0..1 BackboneElement Relationships to other documents
..... code SC 1..1 code replaces | transforms | signs | appends
Constraints: drdr-34-882-1
..... target SC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent S 0..1 BackboneElement Relationships to other documents
..... code SC 1..1 code replaces | transforms | signs | appends
Constraints: drdr-34-884-1
..... target SC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description S 0..1 string Human-readable description
... securityLabel 0..* CodeableConcept Document security-tags
... content
.... id 0..1 string Unique id for inter-element referencing
.... attachment
..... id S 0..1 string Unique id for inter-element referencing
..... contentType 0..1 code Mime type of the content, with charset etc.
Required Pattern: text/plain
..... language 0..1 code Human language of the content (BCP-47)
..... url 0..1 url Uri where the data can be found
..... size S 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash S 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title S 0..1 string Label to display in place of the data
..... creation S 0..1 dateTime Date attachment was first created
.... format 0..1 Coding Format/content rules for the document
... context
.... id 0..1 string Unique id for inter-element referencing
.... encounter 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 0..* CodeableConcept Main clinical acts documented
.... period
..... start S 0..1 dateTime Starting time with inclusive boundary
..... end S 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
.... practiceSetting S 0..1 CodeableConcept 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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG

Constraints

Id Grade Path(s) Description Expression
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* USCoreDocumentReferenceProfile(5.0.1) A reference to a document
This profile also complies with the profiles US Core DocumentReference Profile (6.1.0) and US Core DocumentReference Profile (7.0.0)
... 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
... 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 Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* 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 0..1 uri The namespace for the identifier value
Required Pattern: http://va.gov/identifiers/{sta3n}/8925
.... 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(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
Required Pattern: current
... docStatus SΣC 0..1 code preliminary | final | amended | entered-in-error
Binding: documentReferencedocStatus FHIR (required): see mapping VF_documentReferencedocStatus
Constraints: drdr-34-1787, drdr-34-1788, drdr-34-1789
... type SΣ 1..1 CodeableConcept 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'
Additional BindingsPurpose
US Core Clinical Note Type Min Binding
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by value:$this
..... coding:va-loinc SΣ 0..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 0..1 uri Identity of the terminology system
Required Pattern: http://loinc.org
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 0..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text SΣ 0..1 string Plain text representation of the concept
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... category:us-core SΣ 0..* CodeableConcept 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.

Required Pattern: At least the following
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... coding 1..* Coding Code defined by a terminology system
Fixed Value: (Complex)
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: clinical-note
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner) Who and/or what authored the document
... authenticator S 0..1 Reference(Practitioner) Who/what authenticated the document
... custodian S 0..1 Reference(Organization) Organization which maintains the document
... Slices for relatesTo Σ 0..* BackboneElement Relationships to other documents
Slice: Unordered, Open by value:$this
.... relatesTo: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
..... 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
.... relatesTo:va-parent SΣ 0..1 BackboneElement Relationships to other documents
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-882-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-882
.... relatesTo:va-id-parent SΣ 0..1 BackboneElement Relationships to other documents
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... code SΣC 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
Constraints: drdr-34-884-1
..... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: drdr-34-884
... description SΣ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: us-core-6
..... id S 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 0..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.
Required Pattern: text/plain
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash SΣ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 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 SΣ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile(7.0.0)) Context of the document content
.... event S 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
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... start SΣC 0..1 dateTime Starting time with inclusive boundary
..... end SΣC 0..1 dateTime End time with inclusive boundary, if not ongoing
.... facilityType S 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting S 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

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📦4.0.1 FHIR Std.
DocumentReference.docStatus Base required documentReferencedocStatus FHIR 📦1.10.0 This IG
DocumentReference.type Base required US Core DocumentReference Type 📦7.0.0 US Core v7.0
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category:us-core Base required US Core DocumentReference Category 📦7.0.0 US Core v7.0
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-parent.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo:va-id-parent.​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 v6.5
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.

Constraints

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()
drdr-34-882 best practice DocumentReference.relatesTo:va-parent.target If not null then source value from (8925-.06) true
drdr-34-884 best practice DocumentReference.relatesTo:va-id-parent.target If not null then source value from (8925-2101) true
drdr-34-1787 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501128 INACTIVE then exclude record true
drdr-34-1788 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501287 PURGED then exclude record true
drdr-34-1789 best practice DocumentReference.docStatus If (8925-.05 > 8925.6-.01) is 4501289 TEST then exclude record true
drdr-34-884-1 best practice DocumentReference.relatesTo:va-id-parent.code If not null then fixed value #appends true
drdr-34-882-1 best practice DocumentReference.relatesTo:va-parent.code If not null then fixed value #appends true
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

Summary

Must-Support: 25 elements

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DocumentReference.type.coding
  • The element 1 is sliced based on the value of DocumentReference.relatesTo

 

Other representations of profile: CSV, Excel, Schematron