MediRecords FHIR Implementation Guide
1.4.1 - release


Resource Profile: MR DocumentReference Admission

Defining URL:https://fhir.medirecords.com/StructureDefinition/mr-documentreference-admission
Version:1.4.1
Name:MRDocumentReferenceAdmission
Title:MR DocumentReference Admission
Status:Active as of 2025-02-03 04:29:41+0000
Definition:

MediRecords DocumentReference profile for Admissions

Source Resource:XML / JSON / Turtle

The official URL for this profile is: 

https://fhir.medirecords.com/StructureDefinition/mr-documentreference-admission

Formal Views of Profile Content

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

This structure is derived from MRDocumentReference

Summary

Mandatory: 10 elements
Must-Support: 6 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* MRDocumentReference A reference to a document
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:recipient S 0..1 MRDocumentRefRecipientExtn Handover recipient
..... value[x] 1..1 Reference(MR Practitioner) Received by
.... extension:documentTitle S 1..1 MRDocumentRefTitleExtn MR DocumentReference Title Extension
..... value[x] 1..1 string Title for this document indicating note type, category and initiated date
... docStatus 0..1 code Medirecords only supports final (completed) document status for admission notes
Fixed Value: final
... category 1..1 CodeableConcept Category of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... date 1..1 instant Date that this admission note was initiated
... author S 1..1 Reference(MR Practitioner) The user who authored this admission note
... authenticator S 0..1 Reference(MR Practitioner) The user from the practice who verified or received this Handover Note
... content S 1..1 BackboneElement Document referenced
.... attachment 1..1 Attachment Generated admission note as a PDF
..... contentType 1..1 code application/pdf
..... data 1..1 base64Binary The admission note attachment
... context S 1..1 BackboneElement Clinical context of document
.... encounter 1..1 Reference(MR Encounter Admission) The encounter that this admission note is associated with

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* MRDocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta S 0..1 MRMeta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security SΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... recipient S 0..1 (Complex) Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn"
..... value[x] 1..1 Reference(MR Practitioner) Received by
.... documentTitle S 1..1 (Complex) MR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn"
..... value[x] 1..1 string Title for this document indicating note type, category and initiated date
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!SΣC 1..1 code Indicates if document is Active(current) or Inactive(entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.


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'
... docStatus SΣ 0..1 code Medirecords only supports final (completed) document status for admission notes
Binding: CompositionStatus (required): Status of the underlying document.


Fixed Value: final
... type SΣ 1..1 CodeableConcept Type of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category SΣ 1..1 CodeableConcept Category of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject SΣ 1..1 Reference(MR Patient) The patient who is the subject of the document
... date SΣ 1..1 instant Date that this admission note was initiated
... author SΣ 1..1 Reference(MR Practitioner) The user who authored this admission note
... authenticator S 0..1 Reference(MR Practitioner) The user from the practice who verified or received this Handover Note
... custodian S 1..1 Reference(MR Organisation) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Generated admission note as a PDF
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code application/pdf
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 1..1 base64Binary The admission note attachment
..... url Σ 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 0..1 string The file name of the attachment
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ 1..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 1..1 Reference(MR Encounter Admission) The encounter that this admission note is associated with
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* MRDocumentReference A reference to a document
... meta 0..1 MRMeta Metadata about a resource
.... lastUpdated Σ 0..1 instant When the resource version last changed
.... security ΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
... Slices for extension Content/Rules for all slices
.... recipient 0..1 Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
.... documentTitle 1..1 string MR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... status ?!ΣC 1..1 code Indicates if document is Active(current) or Inactive(entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.


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'
... type Σ 1..1 CodeableConcept Type of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category Σ 1..1 CodeableConcept Category of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject Σ 1..1 Reference(MR Patient) The patient who is the subject of the document
... date Σ 1..1 instant Date that this admission note was initiated
... author Σ 1..1 Reference(MR Practitioner) The user who authored this admission note
... authenticator 0..1 Reference(MR Practitioner) The user from the practice who verified or received this Handover Note
... custodian 1..1 Reference(MR Organisation) Organization which maintains the document
... content Σ 1..1 BackboneElement Document referenced
.... attachment Σ 1..1 Attachment Generated admission note as a PDF
..... contentType Σ 1..1 code application/pdf
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.

..... data 1..1 base64Binary The admission note attachment
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... title Σ 0..1 string The file name of the attachment
... context Σ 1..1 BackboneElement Clinical context of document
.... encounter 1..1 Reference(MR Encounter Admission) The encounter that this admission note is associated with

doco Documentation for this format

This structure is derived from MRDocumentReference

Summary

Mandatory: 10 elements
Must-Support: 6 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

Differential View

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* MRDocumentReference A reference to a document
... extension 1..* Extension Extension
... Slices for extension Content/Rules for all slices
.... extension:recipient S 0..1 MRDocumentRefRecipientExtn Handover recipient
..... value[x] 1..1 Reference(MR Practitioner) Received by
.... extension:documentTitle S 1..1 MRDocumentRefTitleExtn MR DocumentReference Title Extension
..... value[x] 1..1 string Title for this document indicating note type, category and initiated date
... docStatus 0..1 code Medirecords only supports final (completed) document status for admission notes
Fixed Value: final
... category 1..1 CodeableConcept Category of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... date 1..1 instant Date that this admission note was initiated
... author S 1..1 Reference(MR Practitioner) The user who authored this admission note
... authenticator S 0..1 Reference(MR Practitioner) The user from the practice who verified or received this Handover Note
... content S 1..1 BackboneElement Document referenced
.... attachment 1..1 Attachment Generated admission note as a PDF
..... contentType 1..1 code application/pdf
..... data 1..1 base64Binary The admission note attachment
... context S 1..1 BackboneElement Clinical context of document
.... encounter 1..1 Reference(MR Encounter Admission) The encounter that this admission note is associated with

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* MRDocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta S 0..1 MRMeta Metadata about a resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Version specific identifier
.... lastUpdated SΣ 0..1 instant When the resource version last changed
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 1..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security SΣC 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


inv-mr-meta-security-01: Medirecords supports only U, R security code
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".


... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... Slices for extension 1..* Extension Extension
Slice: Unordered, Open by value:url
.... recipient S 0..1 (Complex) Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn"
..... value[x] 1..1 Reference(MR Practitioner) Received by
.... documentTitle S 1..1 (Complex) MR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..0
..... url 1..1 uri "https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn"
..... value[x] 1..1 string Title for this document indicating note type, category and initiated date
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!SΣC 1..1 code Indicates if document is Active(current) or Inactive(entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.


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'
... docStatus SΣ 0..1 code Medirecords only supports final (completed) document status for admission notes
Binding: CompositionStatus (required): Status of the underlying document.


Fixed Value: final
... type SΣ 1..1 CodeableConcept Type of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category SΣ 1..1 CodeableConcept Category of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject SΣ 1..1 Reference(MR Patient) The patient who is the subject of the document
... date SΣ 1..1 instant Date that this admission note was initiated
... author SΣ 1..1 Reference(MR Practitioner) The user who authored this admission note
... authenticator S 0..1 Reference(MR Practitioner) The user from the practice who verified or received this Handover Note
... custodian S 1..1 Reference(MR Organisation) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Generated admission note as a PDF
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code application/pdf
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 1..1 base64Binary The admission note attachment
..... url Σ 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 0..1 string The file name of the attachment
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ 1..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 1..1 Reference(MR Encounter Admission) The encounter that this admission note is associated with
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

 

Other representations of profile: CSV, Excel, Schematron

Terminology Bindings

PathConformanceValueSet / CodeURI
DocumentReference.meta.securityextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.meta.tagexampleCommonTags
http://hl7.org/fhir/ValueSet/common-tags
from the FHIR Standard
DocumentReference.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredFixed Value: final
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typeextensibleMRDocumentAdmissionTypeValueSet
https://fhir.medirecords.com/ValueSet/mr-document-admission-type
from this IG
DocumentReference.categoryextensibleMRAdmissionNoteCategory
https://fhir.medirecords.com/ValueSet/mr-admission-note-category
from this IG
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
inv-mr-docref-in-status-01errorDocumentReference.statusMediRecords 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')
inv-mr-meta-security-01errorDocumentReference.meta.securityMedirecords supports only U, R security code
: code.exists() implies (code = 'U' or code = 'R')