CH Core (R4)
3.0.0 - STU3
CH Core (R4)
3.0.0 - STU3
This page is part of the CH Core (R4) (v3.0.0: STU 3) based on FHIR R4. . For a full list of available versions, see the Directory of published versions 
| Official URL: http://fhir.ch/ig/ch-core/StructureDefinition/ch-core-documentreference-epr | Version: 3.0.0 | |||
| Active as of 2019-11-14 | Computable Name: CHCoreDocumentReferenceEPR | |||
Copyright/Legal: CC-BY-SA-4.0 |
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Base definition for a document reference in the context of the electronic patient record (EPR).
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from CHCoreDocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |
  status | 1..1 | code | current | superseded | entered-in-error | |
| type | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. | |
| category | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. | |
  subject | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document | |
  reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| date | 1..1 | instant | When this document reference was created | |
| author | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document | |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |
| securityLabel | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. | |
| content | 1..* | BackboneElement | Document referenced | |
| attachment | 1..1 | Attachment | Where to access the document | |
| contentType | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) | |
| language | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) | |
| url | 1..1 | url | Uri where the data can be found | |
| format | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. | |
 context | 0..1 | BackboneElement | Clinical context of document | |
 facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DocumentReference.type | required | DocumentEntryTypeCode |
| DocumentReference.category | required | DocumentEntryClassCode |
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode |
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType |
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode |
| DocumentReference.content.format | required | DocumentEntryFormatCode |
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode |
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
 type | Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. |
| category | Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. |
| subject | Σ | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date | Σ | 1..1 | instant | When this document reference was created |
| author | Σ | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |
| securityLabel | Σ | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. |
| content | Σ | 1..* | BackboneElement | Document referenced |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment | Σ | 1..1 | Attachment | Where to access the document |
| contentType | ΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) Example General: text/plain; charset=UTF-8, image/png |
| language | Σ | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) Example General: en-AU |
| url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| format | Σ | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. |
| context | Σ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DocumentReference.status | required | DocumentReferenceStatus |
| DocumentReference.type | required | DocumentEntryTypeCode |
| DocumentReference.category | required | DocumentEntryClassCode |
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode |
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType |
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode |
| DocumentReference.content.format | required | DocumentEntryFormatCode |
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode |
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
| Id | Grade | Path(s) | Details | Requirements |
| ch-docref-1 | warning | DocumentReference.content.attachment.contentType | The following ValueSet is preferred: http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.mimeType : exists() | |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |||||
| 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: CommonLanguages (preferred): A human language.
| |||||
| 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): The status of the document reference. | ||||
| docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. | ||||
| category | Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. | ||||
| subject | Σ | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| date | Σ | 1..1 | instant | When this document reference was created | ||||
| author | Σ | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |||||
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |||||
| relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!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(CH Core DocumentReference) | Target of the relationship | ||||
| description | Σ | 0..1 | string | Human-readable description | ||||
| securityLabel | Σ | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content | Σ | 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 | Σ | 1..1 | Attachment | Where to access the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType | ΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) Example General: text/plain; charset=UTF-8, image/png | ||||
| language | Σ | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) Example General: en-AU | ||||
| data | 0..1 | base64Binary | Data inline, base64ed | |||||
| url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
| format | Σ | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. | ||||
| context | Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter | 0..* | Reference(CH Core Encounter | EpisodeOfCare) | Context of the document content | |||||
| event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period | Σ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |||||
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |||||
| related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DocumentReference.language | preferred | CommonLanguages
| ||||
| DocumentReference.status | required | DocumentReferenceStatus | ||||
| DocumentReference.docStatus | required | CompositionStatus | ||||
| DocumentReference.type | required | DocumentEntryTypeCode | ||||
| DocumentReference.category | required | DocumentEntryClassCode | ||||
| DocumentReference.subject.type | extensible | ResourceType | ||||
| DocumentReference.author.type | extensible | ResourceType | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipType | ||||
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode | ||||
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType | ||||
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode | ||||
| DocumentReference.content.format | required | DocumentEntryFormatCode | ||||
| DocumentReference.context.event | example | ActCode | ||||
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode | ||||
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
| Id | Grade | Path(s) | Details | Requirements |
| ch-docref-1 | warning | DocumentReference.content.attachment.contentType | The following ValueSet is preferred: http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.mimeType : exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CHCoreDocumentReference
Summary
Mandatory: 12 elements
Structures
This structure refers to these other structures:
Differential View
This structure is derived from CHCoreDocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |
| status | 1..1 | code | current | superseded | entered-in-error | |
| type | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. | |
| category | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. | |
| subject | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document | |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| date | 1..1 | instant | When this document reference was created | |
| author | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document | |
| reference | 1..1 | string | Literal reference, Relative, internal or absolute URL | |
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |
| securityLabel | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. | |
| content | 1..* | BackboneElement | Document referenced | |
| attachment | 1..1 | Attachment | Where to access the document | |
| contentType | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) | |
| language | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) | |
| url | 1..1 | url | Uri where the data can be found | |
| format | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. | |
| context | 0..1 | BackboneElement | Clinical context of document | |
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DocumentReference.type | required | DocumentEntryTypeCode |
| DocumentReference.category | required | DocumentEntryClassCode |
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode |
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType |
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode |
| DocumentReference.content.format | required | DocumentEntryFormatCode |
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode |
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| type | Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. |
| category | Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. |
| subject | Σ | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| date | Σ | 1..1 | instant | When this document reference was created |
| author | Σ | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document |
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL |
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |
| securityLabel | Σ | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. |
| content | Σ | 1..* | BackboneElement | Document referenced |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| attachment | Σ | 1..1 | Attachment | Where to access the document |
| contentType | ΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) Example General: text/plain; charset=UTF-8, image/png |
| language | Σ | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) Example General: en-AU |
| url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png |
| format | Σ | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. |
| context | Σ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| DocumentReference.status | required | DocumentReferenceStatus |
| DocumentReference.type | required | DocumentEntryTypeCode |
| DocumentReference.category | required | DocumentEntryClassCode |
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode |
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType |
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode |
| DocumentReference.content.format | required | DocumentEntryFormatCode |
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode |
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
| Id | Grade | Path(s) | Details | Requirements |
| ch-docref-1 | warning | DocumentReference.content.attachment.contentType | The following ValueSet is preferred: http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.mimeType : exists() | |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty() | |
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference | 0..* | CHCoreDocumentReference | CH Core DocumentReference EPR | |||||
| 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: CommonLanguages (preferred): A human language.
| |||||
| 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): The status of the document reference. | ||||
| docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type | Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry.typeCode (required): Precise type of clinical document. | ||||
| category | Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentEntry.classCode (required): High-level kind of a clinical document at a macro level. | ||||
| subject | Σ | 1..1 | Reference(CH Core Patient EPR) | Who/what is the subject of the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| date | Σ | 1..1 | instant | When this document reference was created | ||||
| author | Σ | 1..* | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | Device | CH Core Patient EPR | RelatedPerson) | Who and/or what authored the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference | ΣC | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | ||||
| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known | ||||
| display | Σ | 0..1 | string | Text alternative for the resource | ||||
| authenticator | 0..1 | Reference(CH Core Practitioner EPR | CH Core PractitionerRole EPR | CH Core Organization EPR) | Who/what authenticated the document | |||||
| custodian | 0..1 | Reference(CH Core Organization EPR) | Organization which maintains the document | |||||
| relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!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(CH Core DocumentReference) | Target of the relationship | ||||
| description | Σ | 0..1 | string | Human-readable description | ||||
| securityLabel | Σ | 1..* | CodeableConcept | Document security-tags Binding: DocumentEntry.confidentialityCode (required): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content | Σ | 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 | Σ | 1..1 | Attachment | Where to access the document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType | ΣC | 1..1 | code | Mime type of the content, with charset etc. Binding: DocumentEntry.mimeType (required) Example General: text/plain; charset=UTF-8, image/png | ||||
| language | Σ | 1..1 | code | Human language of the content (BCP-47) Binding: DocumentEntry.languageCode (required) Example General: en-AU | ||||
| data | 0..1 | base64Binary | Data inline, base64ed | |||||
| url | Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation | Σ | 0..1 | dateTime | Date attachment was first created | ||||
| format | Σ | 1..1 | Coding | Format/content rules for the document Binding: DocumentEntry.formatCode (required): Document Format Codes. | ||||
| context | Σ | 0..1 | BackboneElement | Clinical context of document | ||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter | 0..* | Reference(CH Core Encounter | EpisodeOfCare) | Context of the document content | |||||
| event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period | Σ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: DocumentEntry.healthcareFacilityTypeCode (required): XDS Facility Type. | |||||
| practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: DocumentEntry.practiceSettingCode (required): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo | 0..1 | Reference(CH Core Patient EPR) | Patient demographics from source | |||||
| related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| DocumentReference.language | preferred | CommonLanguages
| ||||
| DocumentReference.status | required | DocumentReferenceStatus | ||||
| DocumentReference.docStatus | required | CompositionStatus | ||||
| DocumentReference.type | required | DocumentEntryTypeCode | ||||
| DocumentReference.category | required | DocumentEntryClassCode | ||||
| DocumentReference.subject.type | extensible | ResourceType | ||||
| DocumentReference.author.type | extensible | ResourceType | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipType | ||||
| DocumentReference.securityLabel | required | DocumentEntryConfidentialityCode | ||||
| DocumentReference.content.attachment.contentType | required | DocumentEntryMimeType | ||||
| DocumentReference.content.attachment.language | required | DocumentEntryLanguageCode | ||||
| DocumentReference.content.format | required | DocumentEntryFormatCode | ||||
| DocumentReference.context.event | example | ActCode | ||||
| DocumentReference.context.facilityType | required | DocumentEntryHealthcareFacilityTypeCode | ||||
| DocumentReference.context.practiceSetting | required | DocumentEntryPracticeSettingCode |
| Id | Grade | Path(s) | Details | Requirements |
| ch-docref-1 | warning | DocumentReference.content.attachment.contentType | The following ValueSet is preferred: http://fhir.ch/ig/ch-epr-term/ValueSet/DocumentEntry.mimeType : exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() |
This structure is derived from CHCoreDocumentReference
Summary
Mandatory: 12 elements
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron