MediRecords FHIR Implementation Guide
1.4.1 - release
| Defining URL: | https://fhir.medirecords.com/StructureDefinition/mr-documentreference-in |
| Version: | 1.4.1 |
| Name: | MRDocumentReferenceIn |
| Title: | MR DocumentReference In |
| Status: | Active as of 2024-10-28 02:34:31+0000 |
| Definition: | MediRecords DocumentReference profile for Inbound Correspondence |
| Source Resource: | XML / JSON / Turtle |
The official URL for this profile is:
https://fhir.medirecords.com/StructureDefinition/mr-documentreference-in
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from MRDocumentReference
This structure is derived from MRDocumentReference
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
  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 | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
 recipient | S | 0..1 | Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) | MR DocumentReference Recipient Extension 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" | |||||
  Slices for value[x] | 1..1 | Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) | Document recipient Slice: Unordered, Closed by type:$this | |||||
  value[x]:valueReference | 1..1 | Reference(MR Practitioner) | Document recipient | |||||
| documentTitle | S | 0..1 | string | MR DocumentReference Title Extension URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn | ||||
 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 | Indicates if the document is Unchecked/Draft (preliminary) or Checked/Final (final) or Amended (amended) or Cancelled/Rejected (entered-in-error) Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type | SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: MediRecords Document Reference Letter Type (extensible) | ||||
| category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: MediRecords Document Reference Letter Category (extensible) | ||||
 subject | SΣ | 1..1 | Reference(MR Patient) | The patient who is the subject of the document | ||||
| date | SΣ | 0..1 | instant | When this document reference was created | ||||
| author | SΣ | 0..1 | Reference(MR Practitioner | MR PractitionerRole | MR Organisation) | Who and/or what authored the document | ||||
| authenticator | S | 0..1 | Reference(MR Practitioner) | The user from the practice who checked the document on upload | ||||
| 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 | Σ | 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 | Where to access the document | ||||
| 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 | 0..1 | code | Mime type of the content, with charset etc. Binding: MediRecords Document Reference Letter Attachment Type (required) 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.
Example General: en-AU | ||||
| data | S | 0..1 | base64Binary | Data inline, base64ed | ||||
| 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 | Σ | 0..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 | 0..1 | Reference(MR Encounter | MR Encounter Admission) | This is the encounter where the document was uploaded | ||||
| 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 | |||||
| Documentation for this format | ||||||||
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| 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 |
| recipient | 0..1 | Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) | MR DocumentReference Recipient Extension URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn | |
| documentTitle | 0..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' |
| docStatus | Σ | 0..1 | code | Indicates if the document is Unchecked/Draft (preliminary) or Checked/Final (final) or Amended (amended) or Cancelled/Rejected (entered-in-error) Binding: CompositionStatus (required): Status of the underlying document. |
| type | Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: MediRecords Document Reference Letter Type (extensible) |
| category | Σ | 1..1 | CodeableConcept | Categorization of document Binding: MediRecords Document Reference Letter Category (extensible) |
| subject | Σ | 1..1 | Reference(MR Patient) | The patient who is the subject of the document |
| date | Σ | 0..1 | instant | When this document reference was created |
| author | Σ | 0..1 | Reference(MR Practitioner | MR PractitionerRole | MR Organisation) | Who and/or what authored the document |
| authenticator | 0..1 | Reference(MR Practitioner) | The user from the practice who checked the document on upload | |
| custodian | 1..1 | Reference(MR Organisation) | Organization which maintains the document | |
| content | Σ | 1..* | BackboneElement | Document referenced |
| attachment | Σ | 1..1 | Attachment | Where to access the document |
| contentType | Σ | 0..1 | code | Mime type of the content, with charset etc. Binding: MediRecords Document Reference Letter Attachment Type (required) |
| data | 0..1 | base64Binary | Data inline, base64ed | |
| 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 | 0..1 | BackboneElement | Clinical context of document |
| encounter | 0..1 | Reference(MR Encounter | MR Encounter Admission) | This is the encounter where the document was uploaded | |
| Documentation for this format | ||||
This structure is derived from MRDocumentReference
Differential View
This structure is derived from MRDocumentReference
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| 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 | ||||
| language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained | 0..* | Resource | Contained, inline Resources | |||||
| Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
| recipient | S | 0..1 | Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) | MR DocumentReference Recipient Extension 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" | |||||
| Slices for value[x] | 1..1 | Reference(MR Practitioner | MR Organisation | MR Patient | MR PractitionerRole) | Document recipient Slice: Unordered, Closed by type:$this | |||||
| value[x]:valueReference | 1..1 | Reference(MR Practitioner) | Document recipient | |||||
| documentTitle | S | 0..1 | string | MR DocumentReference Title Extension URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn | ||||
| 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 | Indicates if the document is Unchecked/Draft (preliminary) or Checked/Final (final) or Amended (amended) or Cancelled/Rejected (entered-in-error) Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type | SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: MediRecords Document Reference Letter Type (extensible) | ||||
| category | SΣ | 1..1 | CodeableConcept | Categorization of document Binding: MediRecords Document Reference Letter Category (extensible) | ||||
| subject | SΣ | 1..1 | Reference(MR Patient) | The patient who is the subject of the document | ||||
| date | SΣ | 0..1 | instant | When this document reference was created | ||||
| author | SΣ | 0..1 | Reference(MR Practitioner | MR PractitionerRole | MR Organisation) | Who and/or what authored the document | ||||
| authenticator | S | 0..1 | Reference(MR Practitioner) | The user from the practice who checked the document on upload | ||||
| 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 | Σ | 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 | Where to access the document | ||||
| 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 | 0..1 | code | Mime type of the content, with charset etc. Binding: MediRecords Document Reference Letter Attachment Type (required) 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.
Example General: en-AU | ||||
| data | S | 0..1 | base64Binary | Data inline, base64ed | ||||
| 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 | Σ | 0..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 | 0..1 | Reference(MR Encounter | MR Encounter Admission) | This is the encounter where the document was uploaded | ||||
| 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 | |||||
| Documentation for this format | ||||||||
Other representations of profile: CSV, Excel, Schematron
| Path | Conformance | ValueSet | URI | |||
| DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsfrom the FHIR Standard | ||||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1from the FHIR Standard | ||||
| DocumentReference.type | extensible | MRDocumentLetterTypehttps://fhir.medirecords.com/ValueSet/mr-document-letter-typefrom this IG | ||||
| DocumentReference.category | extensible | MRDocumentLetterCategoryhttps://fhir.medirecords.com/ValueSet/mr-document-letter-categoryfrom this IG | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | MRDocumentLetterAttachmentTypehttps://fhir.medirecords.com/ValueSet/mr-document-letter-attachment-typefrom this IG | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)http://hl7.org/fhir/ValueSet/formatcodesfrom the FHIR Standard | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodesfrom the FHIR Standard | ||||
| DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codesfrom the FHIR Standard |
| Id | Grade | Path(s) | Details | Requirements |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() | |
| dom-3 | error | DocumentReference | 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 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty() | |
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty() | |
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management : text.`div`.exists() | |
| ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count()) | |
| ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both : extension.exists() != value.exists() | |
| inv-mr-docref-in-status-01 | error | DocumentReference.status | 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') | |
| inv-mr-meta-security-01 | error | DocumentReference.meta.security | Medirecords supports only U, R security code : code.exists() implies (code = 'U' or code = 'R') |
