MediRecords FHIR Implementation Guide
1.4.0 - release


Resource Profile: MR DocumentReference Out

Defining URL:https://fhir.medirecords.com/StructureDefinition/mr-documentreference-out
Version:1.4.0
Name:MRDocumentReferenceOut
Title:MR DocumentReference Out
Status:Active as of 2024-06-28 01:25:00+0000
Definition:

MediRecords DocumentReference profile for Outbound Correspondence

Source Resource:XML / JSON / Turtle

The official URL for this profile is:

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

Formal Views of Profile Content

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

This structure is derived from MRDocumentReference

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... extension:recipient S0..1MRDocumentRefRecipientExtnMR DocumentReference Recipient Extension
... extension:documentTitle S0..1MRDocumentRefTitleExtnMR DocumentReference Title Extension
... type 0..1CodeableConceptKind of document (LOINC if possible)
Binding: MediRecords Document Reference Letter Type (extensible)
... author S1..1Reference(MR PractitionerRole)Who and/or what authored the document
... authenticator S0..1Reference(MR Practitioner)The user from the practice who checked the document on upload
... content
.... attachment
..... contentType 0..1codeMime type of the content, with charset etc.
Binding: MediRecords Document Reference Letter Attachment Type (required)

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 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(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..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 | MR Organisation | MR Patient)Document recipient
... documentTitle S0..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... 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..1codeIndicates 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 SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: MediRecords Document Reference Letter Type (extensible)
... category SΣ1..1CodeableConceptCategorization of document
Binding: MediRecords Document Reference Letter Category (extensible)
... subject SΣ1..1Reference(MR Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ1..1Reference(MR PractitionerRole)Who and/or what authored the document
... authenticator S0..1Reference(MR Practitioner)The user from the practice who checked the document on upload
... 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 Σ1..*BackboneElementDocument 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..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ0..1codeMime 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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S0..1base64BinaryData inline, base64ed
..... 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 Σ0..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 S0..1Reference(MR Encounter)Context of the document content
.... 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)MR DocumentReference Recipient Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
... documentTitle 0..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... docStatus Σ0..1codeIndicates 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 Σ0..1CodeableConceptKind of document (LOINC if possible)
Binding: MediRecords Document Reference Letter Type (extensible)
... category Σ1..1CodeableConceptCategorization of document
Binding: MediRecords Document Reference Letter Category (extensible)
... subject Σ1..1Reference(MR Patient)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ1..1Reference(MR PractitionerRole)Who and/or what authored the document
... authenticator 0..1Reference(MR Practitioner)The user from the practice who checked the document on upload
... custodian 1..1Reference(MR Organisation)Organization which maintains the document
... content Σ1..*BackboneElementDocument referenced
.... attachment Σ1..1AttachmentWhere to access the document
..... contentType Σ0..1codeMime type of the content, with charset etc.
Binding: MediRecords Document Reference Letter Attachment Type (required)
..... data 0..1base64BinaryData inline, base64ed
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... title Σ0..1stringThe file name of the attachment
... context Σ0..1BackboneElementClinical context of document
.... encounter 0..1Reference(MR Encounter)Context of the document content

doco Documentation for this format

This structure is derived from MRDocumentReference

Summary

Mandatory: 1 element
Must-Support: 4 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from MRDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*MRDocumentReferenceA reference to a document
... extension:recipient S0..1MRDocumentRefRecipientExtnMR DocumentReference Recipient Extension
... extension:documentTitle S0..1MRDocumentRefTitleExtnMR DocumentReference Title Extension
... type 0..1CodeableConceptKind of document (LOINC if possible)
Binding: MediRecords Document Reference Letter Type (extensible)
... author S1..1Reference(MR PractitionerRole)Who and/or what authored the document
... authenticator S0..1Reference(MR Practitioner)The user from the practice who checked the document on upload
... content
.... attachment
..... contentType 0..1codeMime type of the content, with charset etc.
Binding: MediRecords Document Reference Letter Attachment Type (required)

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 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(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..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 | MR Organisation | MR Patient)Document recipient
... documentTitle S0..1stringMR DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... 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..1codeIndicates 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 SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: MediRecords Document Reference Letter Type (extensible)
... category SΣ1..1CodeableConceptCategorization of document
Binding: MediRecords Document Reference Letter Category (extensible)
... subject SΣ1..1Reference(MR Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ1..1Reference(MR PractitionerRole)Who and/or what authored the document
... authenticator S0..1Reference(MR Practitioner)The user from the practice who checked the document on upload
... 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 Σ1..*BackboneElementDocument 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..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ0..1codeMime 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 Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data S0..1base64BinaryData inline, base64ed
..... 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 Σ0..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 S0..1Reference(MR Encounter)Context of the document content
.... 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

PathConformanceValueSetURI
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.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typeextensibleMRDocumentLetterType
https://fhir.medirecords.com/ValueSet/mr-document-letter-type
from this IG
DocumentReference.categoryextensibleMRDocumentLetterCategory
https://fhir.medirecords.com/ValueSet/mr-document-letter-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.contentTyperequiredMRDocumentLetterAttachmentType
https://fhir.medirecords.com/ValueSet/mr-document-letter-attachment-type
from this IG
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')