Definitions for the mr-documentreference-admission resource profile.
Guidance on how to interpret the contents of this table can be found here
0. DocumentReference | |||||
Definition | 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. | ||||
Short | A reference to a document | ||||
Comments | Usually, this is used for documents other than those defined by FHIR. | ||||
Control | 0..* | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources (contained.contained.empty() )dom-3: 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: 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: If a resource is contained in another resource, it SHALL NOT have a security label ( contained.meta.security.empty() )dom-6: A resource should have narrative for robust management ( text.`div`.exists() ) | ||||
2. DocumentReference.id | |||||
Definition | The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. | ||||
Short | Logical id of this artifact | ||||
Comments | The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Summary | true | ||||
4. DocumentReference.meta | |||||
Definition | The metadata about a resource. This is content in the resource that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource. | ||||
Short | Metadata about a resource | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Meta(MR Meta DataType) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
6. DocumentReference.meta.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
8. DocumentReference.meta.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.meta.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
10. DocumentReference.meta.versionId | |||||
Definition | The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. | ||||
Short | Version specific identifier | ||||
Comments | The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. | ||||
Control | 0..1 | ||||
Type | id | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
12. DocumentReference.meta.lastUpdated | |||||
Definition | When the resource last changed - e.g. when the version changed. | ||||
Short | When the resource version last changed | ||||
Comments | This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. | ||||
Control | 0..1 | ||||
Type | instant | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
14. DocumentReference.meta.source | |||||
Definition | A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. | ||||
Short | Identifies where the resource comes from | ||||
Comments | In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
16. DocumentReference.meta.profile | |||||
Definition | A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. | ||||
Short | Profiles this resource claims to conform to | ||||
Comments | It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. | ||||
Control | 1..* | ||||
Type | canonical(StructureDefinition) | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
18. DocumentReference.meta.security | |||||
Definition | Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. | ||||
Short | Security Labels applied to this resource | ||||
Comments | The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. | ||||
Control | 0..* | ||||
Binding | Unless not suitable, these codes SHALL be taken from All Security Labels (extensible to http://hl7.org/fhir/ValueSet/security-labels )Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )inv-mr-meta-security-01: Medirecords supports only U, R security code ( code.exists() implies (code = 'U' or code = 'R') ) | ||||
20. DocumentReference.meta.tag | |||||
Definition | Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. | ||||
Short | Tags applied to this resource | ||||
Comments | The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. | ||||
Control | 0..* | ||||
Binding | For example codes, see CommonTags (example to http://hl7.org/fhir/ValueSet/common-tags )Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
22. DocumentReference.implicitRules | |||||
Definition | A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. | ||||
Short | A set of rules under which this content was created | ||||
Comments | Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc. | ||||
Control | 0..1 | ||||
Type | uri | ||||
Is Modifier | true because This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
24. DocumentReference.language | |||||
Definition | The base language in which the resource is written. | ||||
Short | Language of the resource content | ||||
Comments | Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
26. DocumentReference.text | |||||
Definition | A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. | ||||
Short | Text summary of the resource, for human interpretation | ||||
Comments | Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later. | ||||
Control | 0..1 | ||||
Type | Narrative | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | narrative, html, xhtml, display | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
28. DocumentReference.contained | |||||
Definition | These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. | ||||
Short | Contained, inline Resources | ||||
Comments | This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels. | ||||
Control | 0..* | ||||
Type | Resource | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | inline resources, anonymous resources, contained resources | ||||
30. DocumentReference.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 1..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
32. DocumentReference.extension:recipient | |||||
Slice Name | recipient | ||||
Definition | MediRecords extension for DocumentReference Recipient | ||||
Short | Handover recipient | ||||
Control | 0..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(MR DocumentReference Recipient Extension) (Extension Type: Reference(MR Practitioner, MR Organisation, MR Patient, MR PractitionerRole)) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
34. DocumentReference.extension:recipient.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
36. DocumentReference.extension:recipient.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
38. DocumentReference.extension:recipient.url | |||||
Definition | Source of the definition for the extension code - a logical name or a URL. | ||||
Short | identifies the meaning of the extension | ||||
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. | ||||
Control | 1..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
Fixed Value | https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn | ||||
40. DocumentReference.extension:recipient.value[x] | |||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Document recipient | ||||
Control | 1..1 | ||||
Type | Reference(MR Practitioner, MR Organisation, MR Patient, MR PractitionerRole) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.extension.value[x] . The slices are unordered and Closed, and can be differentiated using the following discriminators: | ||||
42. DocumentReference.extension:recipient.value[x]:valueReference | |||||
Slice Name | valueReference | ||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Received by | ||||
Control | 1..1 | ||||
Type | Reference(MR Practitioner) | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
44. DocumentReference.extension:documentTitle | |||||
Slice Name | documentTitle | ||||
Definition | MediRecords extension for DocumentReference Title | ||||
Short | MR DocumentReference Title Extension | ||||
Control | 1..1 This element is affected by the following invariants: ele-1 | ||||
Type | Extension(MR DocumentReference Title Extension) (Extension Type: string) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
46. DocumentReference.extension:documentTitle.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
48. DocumentReference.extension:documentTitle.extension | |||||
Definition | An Extension | ||||
Short | Extension | ||||
Control | 0..0 | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.extension.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
50. DocumentReference.extension:documentTitle.url | |||||
Definition | Source of the definition for the extension code - a logical name or a URL. | ||||
Short | identifies the meaning of the extension | ||||
Comments | The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension. | ||||
Control | 1..1 | ||||
Type | uri | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
Fixed Value | https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn | ||||
52. DocumentReference.extension:documentTitle.value[x] | |||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Document title | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.extension.value[x] . The slices are unordered and Closed, and can be differentiated using the following discriminators: | ||||
54. DocumentReference.extension:documentTitle.value[x]:valueString | |||||
Slice Name | valueString | ||||
Definition | Value of extension - must be one of a constrained set of the data types (see Extensibility for a list). | ||||
Short | Title for this document indicating note type, category and initiated date | ||||
Control | 1..1 | ||||
Type | string | ||||
[x] Note | See Choice of Data Types for further information about how to use [x] | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
56. DocumentReference.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them | ||||
Summary | false | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
58. DocumentReference.masterIdentifier | |||||
Definition | Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document. | ||||
Short | Master Version Specific Identifier | ||||
Comments | CDA Document Id extension and root. | ||||
Control | 0..1 | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.). | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
60. DocumentReference.identifier | |||||
Definition | Other identifiers associated with the document, including version independent identifiers. | ||||
Short | Other identifiers for the document | ||||
Note | This is a business identifier, not a resource identifier (see discussion) | ||||
Control | 0..* | ||||
Type | Identifier | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
62. DocumentReference.status | |||||
Definition | The status of this document reference. | ||||
Short | Indicates if document is Active(current) or Inactive(entered-in-error) | ||||
Comments | This is the status of the DocumentReference object, which might be independent from the docStatus element. This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from DocumentReferenceStatus (required to http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 )The status of the document reference. | ||||
Type | code | ||||
Is Modifier | true because This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )inv-mr-docref-in-status-01: MediRecords supports only current - 'This is the current reference for this document' or entered-in-error - 'This reference was created in error' ( $this.exists() implies ($this = 'current' or $this = 'entered-in-error') ) | ||||
64. DocumentReference.docStatus | |||||
Definition | The status of the underlying document. | ||||
Short | Medirecords only supports final (completed) document status for admission notes | ||||
Comments | The document that is pointed to might be in various lifecycle states. | ||||
Control | 0..1 | ||||
Binding | The codes SHALL be taken from CompositionStatus (required to http://hl7.org/fhir/ValueSet/composition-status|4.0.1 )Status of the underlying document. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Fixed Value | final | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
66. DocumentReference.type | |||||
Definition | Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced. | ||||
Short | Type of the admission note | ||||
Comments | Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from MediRecords DocumentReference Admission Type ValueSet (extensible to https://fhir.medirecords.com/ValueSet/mr-document-admission-type ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
68. DocumentReference.category | |||||
Definition | A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type. | ||||
Short | Category of the admission note | ||||
Comments | Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching. | ||||
Control | 1..1 | ||||
Binding | Unless not suitable, these codes SHALL be taken from MediRecords Admission Note Category ValueSet (extensible to https://fhir.medirecords.com/ValueSet/mr-admission-note-category ) | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | claxs | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
70. DocumentReference.subject | |||||
Definition | Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure). | ||||
Short | The patient who is the subject of the document | ||||
Control | 1..1 | ||||
Type | Reference(MR Patient) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
72. DocumentReference.date | |||||
Definition | When the document reference was created. | ||||
Short | Date that this admission note was initiated | ||||
Comments | Referencing/indexing time is used for tracking, organizing versions and searching. | ||||
Control | 1..1 | ||||
Type | instant | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Alternate Names | indexed | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
74. DocumentReference.author | |||||
Definition | Identifies who is responsible for adding the information to the document. | ||||
Short | The user who authored this admission note | ||||
Comments | Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). | ||||
Control | 1..1 | ||||
Type | Reference(MR Practitioner) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
76. DocumentReference.authenticator | |||||
Definition | Which person or organization authenticates that this document is valid. | ||||
Short | The user from the practice who verified or received this Handover Note | ||||
Comments | Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator. | ||||
Control | 0..1 | ||||
Type | Reference(MR Practitioner) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
78. DocumentReference.custodian | |||||
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the document. | ||||
Short | Organization which maintains the document | ||||
Comments | Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization. | ||||
Control | 1..1 | ||||
Type | Reference(MR Organisation) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
80. DocumentReference.relatesTo | |||||
Definition | Relationships that this document has with other document references that already exist. | ||||
Short | Relationships to other documents | ||||
Comments | This element is labeled as a modifier because documents that append to other documents are incomplete on their own. | ||||
Control | 0..* | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
82. DocumentReference.relatesTo.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
84. DocumentReference.relatesTo.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
86. DocumentReference.relatesTo.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
88. DocumentReference.relatesTo.code | |||||
Definition | The type of relationship that this document has with anther document. | ||||
Short | replaces | transforms | signs | appends | ||||
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from DocumentRelationshipType (required to http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 )The type of relationship between documents. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
90. DocumentReference.relatesTo.target | |||||
Definition | The target document of this relationship. | ||||
Short | Target of the relationship | ||||
Control | 1..1 | ||||
Type | Reference(DocumentReference) | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
92. DocumentReference.description | |||||
Definition | Human-readable description of the source document. | ||||
Short | Human-readable description | ||||
Comments | What the document is about, a terse summary of the document. | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Helps humans to assess whether the document is of interest. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
94. DocumentReference.securityLabel | |||||
Definition | A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to. | ||||
Short | Document security-tags | ||||
Comments | The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects. | ||||
Control | 0..* | ||||
Binding | Unless not suitable, these codes SHALL be taken from All Security Labels (extensible to http://hl7.org/fhir/ValueSet/security-labels )Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | true | ||||
Requirements | Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
96. DocumentReference.content | |||||
Definition | The document and format referenced. There may be multiple content element repetitions, each with a different format. | ||||
Short | Document referenced | ||||
Control | 1..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
98. DocumentReference.content.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
100. DocumentReference.content.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
102. DocumentReference.content.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
104. DocumentReference.content.attachment | |||||
Definition | The document or URL of the document along with critical metadata to prove content has integrity. | ||||
Short | Generated admission note as a PDF | ||||
Control | 1..1 | ||||
Type | Attachment | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
106. DocumentReference.content.attachment.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
108. DocumentReference.content.attachment.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
Slicing | This element introduces a set of slices on DocumentReference.content.attachment.extension . The slices are unordered and Open, and can be differentiated using the following discriminators: | ||||
110. DocumentReference.content.attachment.contentType | |||||
Definition | Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate. | ||||
Short | application/pdf | ||||
Control | 1..1 | ||||
Binding | The codes SHALL be taken from Mime Types (required to http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 )The mime type of an attachment. Any valid mime type is allowed. | ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Processors of the data need to be able to know how to interpret the data. | ||||
Example | <br/><b>General</b>:text/plain; charset=UTF-8, image/png | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
112. DocumentReference.content.attachment.language | |||||
Definition | The human language of the content. The value can be any valid value according to BCP 47. | ||||
Short | Human language of the content (BCP-47) | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from CommonLanguages (preferred to http://hl7.org/fhir/ValueSet/languages )A human language.
| ||||
Type | code | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Users need to be able to choose between the languages in a set of attachments. | ||||
Example | <br/><b>General</b>:en-AU | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
114. DocumentReference.content.attachment.data | |||||
Definition | The actual data of the attachment - a sequence of bytes, base64 encoded. | ||||
Short | The admission note attachment | ||||
Comments | The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON. | ||||
Control | 1..1 | ||||
Type | base64Binary | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | false | ||||
Requirements | The data needs to able to be transmitted inline. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
116. DocumentReference.content.attachment.url | |||||
Definition | A location where the data can be accessed. | ||||
Short | Uri where the data can be found | ||||
Comments | If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data. | ||||
Control | 0..1 | ||||
Type | url | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | The data needs to be transmitted by reference. | ||||
Example | <br/><b>General</b>:http://www.acme.com/logo-small.png | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
118. DocumentReference.content.attachment.size | |||||
Definition | The number of bytes of data that make up this attachment (before base64 encoding, if that is done). | ||||
Short | Number of bytes of content (if url provided) | ||||
Comments | The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference. | ||||
Control | 0..1 | ||||
Type | unsignedInt | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
120. DocumentReference.content.attachment.hash | |||||
Definition | The calculated hash of the data using SHA-1. Represented using base64. | ||||
Short | Hash of the data (sha-1, base64ed) | ||||
Comments | The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see Provenance.signature for mechanism to protect a resource with a digital signature. | ||||
Control | 0..1 | ||||
Type | base64Binary | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version). | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
122. DocumentReference.content.attachment.title | |||||
Definition | A label or set of text to display in place of the data. | ||||
Short | The file name of the attachment | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Must Support | true | ||||
Summary | true | ||||
Requirements | Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer. | ||||
Example | <br/><b>General</b>:Official Corporate Logo | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
124. DocumentReference.content.attachment.creation | |||||
Definition | The date that the attachment was first created. | ||||
Short | Date attachment was first created | ||||
Control | 0..1 | ||||
Type | dateTime | ||||
Is Modifier | false | ||||
Primitive Value | This primitive element may be present, or absent, or replaced by an extension | ||||
Summary | true | ||||
Requirements | This is often tracked as an integrity issue for use of the attachment. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
126. DocumentReference.content.format | |||||
Definition | An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. | ||||
Short | Format/content rules for the document | ||||
Comments | Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. | ||||
Control | 0..1 | ||||
Binding | The codes SHOULD be taken from DocumentReferenceFormatCodeSet (preferred to http://hl7.org/fhir/ValueSet/formatcodes )Document Format Codes. | ||||
Type | Coding | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
128. DocumentReference.context | |||||
Definition | The clinical context in which the document was prepared. | ||||
Short | Clinical context of document | ||||
Comments | These values are primarily added to help with searching for interesting/relevant documents. | ||||
Control | 1..1 | ||||
Type | BackboneElement | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
130. DocumentReference.context.id | |||||
Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | ||||
Short | Unique id for inter-element referencing | ||||
Control | 0..1 | ||||
Type | string | ||||
Is Modifier | false | ||||
XML Format | In the XML format, this property is represented as an attribute. | ||||
Summary | false | ||||
132. DocumentReference.context.extension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | ||||
Short | Additional content defined by implementations | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | false | ||||
Summary | false | ||||
Alternate Names | extensions, user content | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
134. DocumentReference.context.modifierExtension | |||||
Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | ||||
Short | Extensions that cannot be ignored even if unrecognized | ||||
Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. | ||||
Control | 0..* | ||||
Type | Extension | ||||
Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them | ||||
Summary | true | ||||
Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. | ||||
Alternate Names | extensions, user content, modifiers | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) )ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists() ) | ||||
136. DocumentReference.context.encounter | |||||
Definition | Describes the clinical encounter or type of care that the document content is associated with. | ||||
Short | The encounter that this admission note is associated with | ||||
Control | 1..1 | ||||
Type | Reference(MR Encounter Admission) | ||||
Is Modifier | false | ||||
Must Support | true | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
138. DocumentReference.context.event | |||||
Definition | This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. | ||||
Short | Main clinical acts documented | ||||
Comments | An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation. | ||||
Control | 0..* | ||||
Binding | For example codes, see v3 Code System ActCode (example to http://terminology.hl7.org/ValueSet/v3-ActCode )This list of codes represents the main clinical acts being documented. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
140. DocumentReference.context.period | |||||
Definition | The time period over which the service that is described by the document was provided. | ||||
Short | Time of service that is being documented | ||||
Control | 0..1 | ||||
Type | Period | ||||
Is Modifier | false | ||||
Summary | true | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
142. DocumentReference.context.facilityType | |||||
Definition | The kind of facility where the patient was seen. | ||||
Short | Kind of facility where patient was seen | ||||
Control | 0..1 | ||||
Binding | For example codes, see FacilityTypeCodeValueSet (example to http://hl7.org/fhir/ValueSet/c80-facilitycodes )XDS Facility Type. | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
144. DocumentReference.context.practiceSetting | |||||
Definition | This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. | ||||
Short | Additional details about where the content was created (e.g. clinical specialty) | ||||
Comments | This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. | ||||
Control | 0..1 | ||||
Binding | For example codes, see PracticeSettingCodeValueSet (example to http://hl7.org/fhir/ValueSet/c80-practice-codes )Additional details about where the content was created (e.g. clinical specialty). | ||||
Type | CodeableConcept | ||||
Is Modifier | false | ||||
Summary | false | ||||
Requirements | This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
146. DocumentReference.context.sourcePatientInfo | |||||
Definition | The Patient Information as known when the document was published. May be a reference to a version specific, or contained. | ||||
Short | Patient demographics from source | ||||
Control | 0..1 | ||||
Type | Reference(Patient) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) | ||||
148. DocumentReference.context.related | |||||
Definition | Related identifiers or resources associated with the DocumentReference. | ||||
Short | Related identifiers or resources | ||||
Comments | May be identifiers or resources that caused the DocumentReference or referenced Document to be created. | ||||
Control | 0..* | ||||
Type | Reference(Resource) | ||||
Is Modifier | false | ||||
Summary | false | ||||
Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()) ) |