FHIR Implementation Guide for NDHM CI Build v2.0
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NDHM (R4), Published and maintained by NRCeS for NHA.
This version is based on the NDHM Health Data Interchange Specifications 1.0 and updated periodically.

StructureDefinition-DocumentReference

This profile sets minimum expectations for searching and fetching fetching patient documents including Clinical Notes using the DocumentReference resource. It identifies the mandatory core elements, extensions, vocabularies and value sets which SHALL be present in the DocumentReference resource when using this profile.

Examples

Formal Views of Profile Content

Description of Profiles, Differentials, and Snapshots.

The official URL for this profile is: https://nrces.in/ndhm/fhir/r4/StructureDefinition/DocumentReference

This profile builds on DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codecurrent | superseded | entered-in-error
... subject 0..1Reference(Group | Device | Patient | Practitioner)Who/what is the subject of the document
... author 0..*Reference(Device | RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo
.... target 1..1Reference(DocumentReference)Target of the relationship
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
..... contentType S1..1codeMime type of the content, with charset etc.
..... data S1..1base64BinaryData inline, base64ed
... context
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*DocumentReferenceA reference to a document
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... masterIdentifier ΣI0..1IdentifierMaster Version Specific Identifier
... identifier ΣI0..*IdentifierOther identifiers for the document
... status ?!SΣI1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus ΣI0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type ΣI0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred)
... category ΣI0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example)
... subject ΣI0..1Reference(Group | Device | Patient | Practitioner)Who/what is the subject of the document
... date ΣI0..1instantWhen this document reference was created
... author ΣI0..*Reference(Device | RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)Who and/or what authored the document
... authenticator I0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian I0..1Reference(Organization)Organization which maintains the document
... relatesTo ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target ΣI1..1Reference(DocumentReference)Target of the relationship
... description ΣI0..1stringHuman-readable description
... securityLabel ΣI0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣI1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣI1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required)
Example General: text/plain; charset=UTF-8, image/png
..... language ΣI0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
Example General: en-AU
..... data SI1..1base64BinaryData inline, base64ed
..... url ΣI0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size ΣI0..1unsignedIntNumber of bytes of content (if url provided)
..... hash ΣI0..1base64BinaryHash of the data (sha-1, base64ed)
..... title ΣI0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation ΣI0..1dateTimeDate attachment was first created
.... format ΣI0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred)
... context ΣI0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter I0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event I0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodTime of service that is being documented
.... facilityType I0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example)
.... practiceSetting I0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example)
.... sourcePatientInfo I0..1Reference(Patient)Patient demographics from source
.... related I0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codecurrent | superseded | entered-in-error
... subject 0..1Reference(Group | Device | Patient | Practitioner)Who/what is the subject of the document
... author 0..*Reference(Device | RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo
.... target 1..1Reference(DocumentReference)Target of the relationship
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
..... contentType S1..1codeMime type of the content, with charset etc.
..... data S1..1base64BinaryData inline, base64ed
... context
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference I0..*DocumentReferenceA reference to a document
... id Σ0..1stringLogical id of this artifact
... meta ΣI0..1MetaMetadata about the resource
... implicitRules ?!ΣI0..1uriA set of rules under which this content was created
... language I0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
... text I0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension I0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!I0..*ExtensionExtensions that cannot be ignored
... masterIdentifier ΣI0..1IdentifierMaster Version Specific Identifier
... identifier ΣI0..*IdentifierOther identifiers for the document
... status ?!SΣI1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus ΣI0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required)
... type ΣI0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred)
... category ΣI0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example)
... subject ΣI0..1Reference(Group | Device | Patient | Practitioner)Who/what is the subject of the document
... date ΣI0..1instantWhen this document reference was created
... author ΣI0..*Reference(Device | RelatedPerson | Practitioner | PractitionerRole | Organization | Patient)Who and/or what authored the document
... authenticator I0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian I0..1Reference(Organization)Organization which maintains the document
... relatesTo ΣI0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code ΣI1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required)
.... target ΣI1..1Reference(DocumentReference)Target of the relationship
... description ΣI0..1stringHuman-readable description
... securityLabel ΣI0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible)
... content SΣI1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣI1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension I0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣI1..1codeMime type of the content, with charset etc.
Binding: Mime Types (required)
Example General: text/plain; charset=UTF-8, image/png
..... language ΣI0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred)
Max Binding: AllLanguages
Example General: en-AU
..... data SI1..1base64BinaryData inline, base64ed
..... url ΣI0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size ΣI0..1unsignedIntNumber of bytes of content (if url provided)
..... hash ΣI0..1base64BinaryHash of the data (sha-1, base64ed)
..... title ΣI0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation ΣI0..1dateTimeDate attachment was first created
.... format ΣI0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred)
... context ΣI0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension I0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!ΣI0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter I0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event I0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example)
.... period ΣI0..1PeriodTime of service that is being documented
.... facilityType I0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example)
.... practiceSetting I0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example)
.... sourcePatientInfo I0..1Reference(Patient)Patient demographics from source
.... related I0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron