INTEROPen CareConnect Base STU3 Implementation Guide - Local Development build (v3.0.0). See the Directory of published versions
StructureDefinition: CareConnect-DocumentReference-1
The DocumentReference resource is used to describe a document that is made available to a healthcare system.
The official URL for this profile is:
https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-DocumentReference-1
A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.
Examples
Formal Views of Profile Content
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
Summary
Mandatory: 0 element (7 nested mandatory elements)
Prohibited: 1 element
Structures
This structure refers to these other structures:
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Organization-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Practitioner-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-DocumentReference-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Encounter-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Patient-1
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference | I | 0..* | DocumentReference | A reference to a document |
  id | Σ | 0..1 | id | Logical id of this artifact |
 meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages | |
| text | I | 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 |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| identifier | Σ | 0..* | Identifier | Other identifiers for the document |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
| docStatus | Σ | 0..1 | code | preliminary | final | appended | amended | entered-in-error Binding: CompositionStatus (required) |
| type | Σ | 1..1 | CodeableConcept | Type of document Binding: Care Connect Document Type (preferred) |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| coding | Σ | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system |
| display | Σ | 1..1 | string | Representation defined by the system |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | Σ | 0..1 | string | Plain text representation of the concept |
| class | Σ | 0..1 | CodeableConcept | Categorization of document Binding: Document Class Value Set (example) |
| subject | Σ | 0..1 | Reference(Group | Device | CareConnect-Practitioner-1 | CareConnect-Patient-1) | Who/what is the subject of the document |
| created | Σ | 0..1 | dateTime | Document creation time |
| indexed | Σ | 1..1 | instant | When this document reference was created |
| author | Σ | 0..* | Reference(Device | CareConnect-RelatedPerson-1 | CareConnect-Practitioner-1 | CareConnect-Patient-1 | CareConnect-Organization-1) | Who and/or what authored the document |
| authenticator | Σ | 0..1 | Reference(CareConnect-Practitioner-1 | CareConnect-Organization-1) | Who/what authenticated the document |
| custodian | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization which maintains the document |
| relatesTo | ?!ΣI | 0..* | BackboneElement | Relationships to other documents |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
| target | Σ | 1..1 | Reference(CareConnect-DocumentReference-1) | Target of the relationship |
| description | Σ | 0..1 | string | Human-readable description (title) |
| securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible) |
| content | ΣI | 1..* | BackboneElement | Document referenced |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| attachment | Σ | 1..1 | Attachment | Where to access the document |
| format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReference Format Code Set (preferred) |
 context | ΣI | 0..1 | BackboneElement | Clinical context of document |
 id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| encounter | Σ | 0..1 | Reference(CareConnect-Encounter-1) | Context of the document content |
| event | Σ | 0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (example) |
| period | Σ | 0..1 | Period | Time of service that is being documented |
| facilityType | Σ | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type Code Value Set (example) |
| practiceSetting | Σ | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Care Connect Care Setting Type (preferred) |
| sourcePatientInfo | Σ | 0..1 | Reference(CareConnect-Patient-1) | Patient demographics from source |
| related | ΣI | 0..* | BackboneElement | Related identifiers or resources |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Identifier of related objects or events |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| 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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| ref | Σ | 0..1 | Reference(Resource) | Related Resource |
| Documentation for this format | ||||
This structure is derived from DocumentReference
Summary
Mandatory: 0 element (7 nested mandatory elements)
Prohibited: 1 element
Structures
This structure refers to these other structures:
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Organization-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Practitioner-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-DocumentReference-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Encounter-1
- https://fhir.hl7.org.uk/STU3/StructureDefinition/CareConnect-Patient-1
Differential View
This structure is derived from DocumentReference
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | I | 0..* | DocumentReference | A reference to a document |
| id | Σ | 0..1 | id | Logical id of this artifact |
| meta | Σ | 0..1 | Meta | Metadata about the resource |
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
| language | 0..1 | code | Language of the resource content Binding: Common Languages (extensible) Max Binding: All Languages | |
| text | I | 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 |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| identifier | Σ | 0..* | Identifier | Other identifiers for the document |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 1..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| value | Σ | 1..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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) |
| docStatus | Σ | 0..1 | code | preliminary | final | appended | amended | entered-in-error Binding: CompositionStatus (required) |
| type | Σ | 1..1 | CodeableConcept | Type of document Binding: Care Connect Document Type (preferred) |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| coding | Σ | 0..* | Coding | Code defined by a terminology system |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| system | Σ | 1..1 | uri | Identity of the terminology system |
| code | Σ | 1..1 | code | Symbol in syntax defined by the system |
| display | Σ | 1..1 | string | Representation defined by the system |
| userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user |
| text | Σ | 0..1 | string | Plain text representation of the concept |
| class | Σ | 0..1 | CodeableConcept | Categorization of document Binding: Document Class Value Set (example) |
| subject | Σ | 0..1 | Reference(Group | Device | CareConnect-Practitioner-1 | CareConnect-Patient-1) | Who/what is the subject of the document |
| created | Σ | 0..1 | dateTime | Document creation time |
| indexed | Σ | 1..1 | instant | When this document reference was created |
| author | Σ | 0..* | Reference(Device | CareConnect-RelatedPerson-1 | CareConnect-Practitioner-1 | CareConnect-Patient-1 | CareConnect-Organization-1) | Who and/or what authored the document |
| authenticator | Σ | 0..1 | Reference(CareConnect-Practitioner-1 | CareConnect-Organization-1) | Who/what authenticated the document |
| custodian | Σ | 0..1 | Reference(CareConnect-Organization-1) | Organization which maintains the document |
| relatesTo | ?!ΣI | 0..* | BackboneElement | Relationships to other documents |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required) |
| target | Σ | 1..1 | Reference(CareConnect-DocumentReference-1) | Target of the relationship |
| description | Σ | 0..1 | string | Human-readable description (title) |
| securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible) |
| content | ΣI | 1..* | BackboneElement | Document referenced |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| attachment | Σ | 1..1 | Attachment | Where to access the document |
| format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReference Format Code Set (preferred) |
| context | ΣI | 0..1 | BackboneElement | Clinical context of document |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| encounter | Σ | 0..1 | Reference(CareConnect-Encounter-1) | Context of the document content |
| event | Σ | 0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (example) |
| period | Σ | 0..1 | Period | Time of service that is being documented |
| facilityType | Σ | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type Code Value Set (example) |
| practiceSetting | Σ | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Care Connect Care Setting Type (preferred) |
| sourcePatientInfo | Σ | 0..1 | Reference(CareConnect-Patient-1) | Patient demographics from source |
| related | ΣI | 0..* | BackboneElement | Related identifiers or resources |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations | |
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored |
| identifier | Σ | 0..1 | Identifier | Identifier of related objects or events |
| id | 0..1 | string | xml:id (or equivalent in JSON) | |
| extension | 0..* | Extension | Additional Content defined by implementations Slice: Unordered, Open by value:url | |
| use | ?!Σ | 0..1 | code | usual | official | temp | secondary (If known) Binding: IdentifierUse (required) |
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: Identifier Type Codes (extensible) |
| system | Σ | 0..1 | uri | The namespace for the identifier value Example General: http://www.acme.com/identifiers/patient |
| 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(CareConnect-Organization-1) | Organization that issued id (may be just text) |
| ref | Σ | 0..1 | Reference(Resource) | Related Resource |
| Documentation for this format | ||||
Other representations of profile: Schematron
Terminology Bindings
Terminology Bindings
| Path | Conformance | ValueSet |
| DocumentReference.language | extensible | Common Languages Max Binding: All Languages |
| DocumentReference.masterIdentifier.use | required | IdentifierUse |
| DocumentReference.masterIdentifier.type | extensible | Identifier Type Codes |
| DocumentReference.identifier.use | required | IdentifierUse |
| DocumentReference.identifier.type | extensible | Identifier Type Codes |
| DocumentReference.status | required | DocumentReferenceStatus |
| DocumentReference.docStatus | required | CompositionStatus |
| DocumentReference.type | preferred | Care Connect Document Type |
| DocumentReference.class | example | Document Class Value Set |
| DocumentReference.relatesTo.code | required | DocumentRelationshipType |
| DocumentReference.securityLabel | extensible | All Security Labels |
| DocumentReference.content.format | preferred | DocumentReference Format Code Set |
| DocumentReference.context.event | example | v3 Code System ActCode |
| DocumentReference.context.facilityType | example | Facility Type Code Value Set |
| DocumentReference.context.practiceSetting | preferred | Care Connect Care Setting Type |
| DocumentReference.context.related.identifier.use | required | IdentifierUse |
| DocumentReference.context.related.identifier.type | extensible | Identifier Type Codes |
Constraints
Constraints
| Id | Path | Details | Requirements |
| dom-2 | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-1 | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain any narrative : contained.text.empty() | |
| dom-4 | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-3 | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource : contained.where(('#'+id in %resource.descendants().reference).not()).empty() | |
| ele-1 | DocumentReference.relatesTo | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ele-1 | DocumentReference.content | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ele-1 | DocumentReference.context | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) | |
| ele-1 | DocumentReference.context.related | All FHIR elements must have a @value or children : hasValue() | (children().count() > id.count()) |