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 2024-10-28 02:34:31+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: 11 elements
Must-Support: 6 elements
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DocumentReference.extension.value[x] is sliced based on the value of type:$this

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... extension 1..*ExtensionExtension
... extension:recipient S0..1MRDocumentRefRecipientExtnHandover recipient
.... valueReference 1..1Reference(MR Practitioner)Received by
... extension:documentTitle S1..1MRDocumentRefTitleExtnMR DocumentReference Title Extension
.... value[x] 1..1stringDocument title
Slice: Unordered, Open by type:$this
.... valueString 1..1stringTitle for this document indicating note type, category and initiated date
... type 1..1CodeableConceptType of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category 1..1CodeableConceptCategory of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... date 1..1instantDate that this admission note was initiated
... author S1..1Reference(MR Practitioner)The user who authored this admission note
... authenticator S0..1Reference(MR Practitioner)The user from the practice who verified or received this Handover Note
... content S1..1BackboneElementDocument referenced
.... attachment 1..1AttachmentGenerated admission note as a PDF
..... contentType 1..1codeapplication/pdf
..... data 1..1base64BinaryThe admission note attachment
... context S1..1BackboneElementClinical context of document
.... encounter 1..1Reference(MR Encounter Admission)The encounter that this admission note is associated with

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta S0..1MRMetaMetadata about a resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security SΣC0..*CodingSecurity 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 Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole)Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn"
.... Slices for value[x] 1..1Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole)Document recipient
Slice: Unordered, Closed by type:$this
..... value[x]:valueReference 1..1Reference(MR Practitioner)Received by
... documentTitle S1..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn"
.... Slices for value[x] 1..1stringDocument title
Slice: Unordered, Closed by type:$this
..... value[x]:valueString 1..1stringTitle for this document indicating note type, category and initiated date
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣC1..1codeIndicates 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 SΣ0..1codeMedirecords only supports final (completed) document status for admission notes
Binding: CompositionStatus (required): Status of the underlying document.


Fixed Value: final
... type SΣ1..1CodeableConceptType of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category SΣ1..1CodeableConceptCategory of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject SΣ1..1Reference(MR Patient)The patient who is the subject of the document
... date SΣ1..1instantDate that this admission note was initiated
... author SΣ1..1Reference(MR Practitioner)The user who authored this admission note
... authenticator S0..1Reference(MR Practitioner)The user from the practice who verified or received this Handover Note
... custodian S1..1Reference(MR Organisation)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment Σ1..1AttachmentGenerated admission note as a PDF
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeapplication/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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S1..1base64BinaryThe admission note attachment
..... url Σ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title SΣ0..1stringThe file name of the attachment
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ1..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S1..1Reference(MR Encounter Admission)The encounter that this admission note is associated with
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... meta 0..1MRMetaMetadata about a resource
.... lastUpdated Σ0..1instantWhen the resource version last changed
.... security ΣC0..*CodingSecurity 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
... recipient 0..1Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole)Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
... documentTitle 1..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... docStatus Σ0..1codeMedirecords only supports final (completed) document status for admission notes
Binding: CompositionStatus (required): Status of the underlying document.


Fixed Value: final
... type Σ1..1CodeableConceptType of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category Σ1..1CodeableConceptCategory of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject Σ1..1Reference(MR Patient)The patient who is the subject of the document
... date Σ1..1instantDate that this admission note was initiated
... author Σ1..1Reference(MR Practitioner)The user who authored this admission note
... authenticator 0..1Reference(MR Practitioner)The user from the practice who verified or received this Handover Note
... custodian 1..1Reference(MR Organisation)Organization which maintains the document
... content Σ1..1BackboneElementDocument referenced
.... attachment Σ1..1AttachmentGenerated admission note as a PDF
..... contentType Σ1..1codeapplication/pdf
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.

..... data 1..1base64BinaryThe admission note attachment
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... title Σ0..1stringThe file name of the attachment
... context Σ1..1BackboneElementClinical context of document
.... encounter 1..1Reference(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: 11 elements
Must-Support: 6 elements
Fixed Value: 1 element

Structures

This structure refers to these other structures:

Slices

This structure defines the following Slices:

  • The element DocumentReference.extension.value[x] is sliced based on the value of type:$this

Differential View

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... extension 1..*ExtensionExtension
... extension:recipient S0..1MRDocumentRefRecipientExtnHandover recipient
.... valueReference 1..1Reference(MR Practitioner)Received by
... extension:documentTitle S1..1MRDocumentRefTitleExtnMR DocumentReference Title Extension
.... value[x] 1..1stringDocument title
Slice: Unordered, Open by type:$this
.... valueString 1..1stringTitle for this document indicating note type, category and initiated date
... type 1..1CodeableConceptType of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category 1..1CodeableConceptCategory of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... date 1..1instantDate that this admission note was initiated
... author S1..1Reference(MR Practitioner)The user who authored this admission note
... authenticator S0..1Reference(MR Practitioner)The user from the practice who verified or received this Handover Note
... content S1..1BackboneElementDocument referenced
.... attachment 1..1AttachmentGenerated admission note as a PDF
..... contentType 1..1codeapplication/pdf
..... data 1..1base64BinaryThe admission note attachment
... context S1..1BackboneElementClinical context of document
.... encounter 1..1Reference(MR Encounter Admission)The encounter that this admission note is associated with

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta S0..1MRMetaMetadata about a resource
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ0..1idVersion specific identifier
.... lastUpdated SΣ0..1instantWhen the resource version last changed
.... source Σ0..1uriIdentifies where the resource comes from
.... profile Σ1..*canonical(StructureDefinition)Profiles this resource claims to conform to
.... security SΣC0..*CodingSecurity 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 Σ0..*CodingTags 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 ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 1..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole)Handover recipient
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn"
.... Slices for value[x] 1..1Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole)Document recipient
Slice: Unordered, Closed by type:$this
..... value[x]:valueReference 1..1Reference(MR Practitioner)Received by
... documentTitle S1..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn"
.... Slices for value[x] 1..1stringDocument title
Slice: Unordered, Closed by type:$this
..... value[x]:valueString 1..1stringTitle for this document indicating note type, category and initiated date
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣC1..1codeIndicates 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 SΣ0..1codeMedirecords only supports final (completed) document status for admission notes
Binding: CompositionStatus (required): Status of the underlying document.


Fixed Value: final
... type SΣ1..1CodeableConceptType of the admission note
Binding: MediRecords DocumentReference Admission Type ValueSet (extensible)
... category SΣ1..1CodeableConceptCategory of the admission note
Binding: MediRecords Admission Note Category ValueSet (extensible)
... subject SΣ1..1Reference(MR Patient)The patient who is the subject of the document
... date SΣ1..1instantDate that this admission note was initiated
... author SΣ1..1Reference(MR Practitioner)The user who authored this admission note
... authenticator S0..1Reference(MR Practitioner)The user from the practice who verified or received this Handover Note
... custodian S1..1Reference(MR Organisation)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..1BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment Σ1..1AttachmentGenerated admission note as a PDF
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ1..1codeapplication/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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S1..1base64BinaryThe admission note attachment
..... url Σ0..1urlUri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size SΣ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title SΣ0..1stringThe file name of the attachment
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ1..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S1..1Reference(MR Encounter Admission)The encounter that this admission note is associated with
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(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
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
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')