MediRecords FHIR Implementation Guide
20220926 - ci-build


Resource Profile: MediRecords DocumentReference

Defining URL:https://fhir.medirecords.com/StructureDefinition/mr-documentreference
Version:20220926
Name:MRDocumentReference
Title:MediRecords DocumentReference Base
Status:Active as of 2022-09-28 10:08:29+0000
Definition:

MediRecords DocumentReference base profile for Correspondence

Source Resource:XML / JSON / Turtle

The official URL for this profile is:

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

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceThis is an abstract profile
A reference to a document
... meta S0..1MRMetaMetadata about a resource
.... lastUpdated S0..1instantWhen the resource version last changed
.... security S0..*CodingSecurity Labels applied to this resource
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)MediRecords DocumentReference Recipient Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
.... valueReference 1..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient)Document recipient
... status SC1..1codeIndicates if document is Active(current) or Inactive(entered-in-error)
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 SC0..1codeIndicates if the document is Unchecked (preliminary) or Checked (final)
inv-mr-docref-in-docstatus-01: MediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S1..1CodeableConceptCategorization of document
... subject S1..1Reference(MediRecords Core Patient)Who/what is the subject of the document
... date S0..1instantWhen this document reference was created
... author S0..1Reference(MediRecords Core Practitioner | MediRecords Core PractitionerRole | MediRecords Core Organisation)Who and/or what authored the document
... authenticator S0..1Reference(MediRecords Core Practitioner)The user from the practice who checked the document on upload
... custodian S1..1Reference(MediRecords Core Organisation)Organization which maintains the document
... content
.... attachment
..... contentType S0..1codeMime type of the content, with charset etc.
..... data S0..1base64BinaryData inline, base64ed
..... size S0..1unsignedIntNumber of bytes of content (if url provided)
..... title S0..1stringThe file name of the attachment
... context
.... encounter S0..1Reference(MediRecords Core Encounter)Context of the document content

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceThis is an abstract profile
A 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.


.... 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(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)MediRecords 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(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)Document recipient
Slice: Unordered, Closed by type:$this
..... value[x]:valueReference 1..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient)Document recipient
... documentTitle S0..1stringMediRecords 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 SΣC0..1codeIndicates if the document is Unchecked (preliminary) or Checked (final)
Binding: CompositionStatus (required): Status of the underlying document.


inv-mr-docref-in-docstatus-01: MediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(MediRecords Core Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..1Reference(MediRecords Core Practitioner | MediRecords Core PractitionerRole | MediRecords Core Organisation)Who and/or what authored the document
... authenticator S0..1Reference(MediRecords Core Practitioner)The user from the practice who checked the document on upload
... custodian S1..1Reference(MediRecords Core 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: 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 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(MediRecords Core 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..*DocumentReferenceThis is an abstract profile
A 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.


... recipient 0..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)MediRecords DocumentReference Recipient Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
... documentTitle 0..1stringMediRecords DocumentReference Title Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-title-extn
... docStatus ΣC0..1codeIndicates if the document is Unchecked (preliminary) or Checked (final)
Binding: CompositionStatus (required): Status of the underlying document.


inv-mr-docref-in-docstatus-01: MediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
... type Σ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ1..1Reference(MediRecords Core Patient)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ0..1Reference(MediRecords Core Practitioner | MediRecords Core PractitionerRole | MediRecords Core Organisation)Who and/or what authored the document
... authenticator 0..1Reference(MediRecords Core Practitioner)The user from the practice who checked the document on upload
... custodian 1..1Reference(MediRecords Core 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: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.

..... 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(MediRecords Core Encounter)Context of the document content

doco Documentation for this format

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceThis is an abstract profile
A reference to a document
... meta S0..1MRMetaMetadata about a resource
.... lastUpdated S0..1instantWhen the resource version last changed
.... security S0..*CodingSecurity Labels applied to this resource
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... recipient S0..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)MediRecords DocumentReference Recipient Extension
URL: https://fhir.medirecords.com/StructureDefinition/mr-document-ref-recipient-extn
.... valueReference 1..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient)Document recipient
... status SC1..1codeIndicates if document is Active(current) or Inactive(entered-in-error)
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 SC0..1codeIndicates if the document is Unchecked (preliminary) or Checked (final)
inv-mr-docref-in-docstatus-01: MediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
... type S0..1CodeableConceptKind of document (LOINC if possible)
... category S1..1CodeableConceptCategorization of document
... subject S1..1Reference(MediRecords Core Patient)Who/what is the subject of the document
... date S0..1instantWhen this document reference was created
... author S0..1Reference(MediRecords Core Practitioner | MediRecords Core PractitionerRole | MediRecords Core Organisation)Who and/or what authored the document
... authenticator S0..1Reference(MediRecords Core Practitioner)The user from the practice who checked the document on upload
... custodian S1..1Reference(MediRecords Core Organisation)Organization which maintains the document
... content
.... attachment
..... contentType S0..1codeMime type of the content, with charset etc.
..... data S0..1base64BinaryData inline, base64ed
..... size S0..1unsignedIntNumber of bytes of content (if url provided)
..... title S0..1stringThe file name of the attachment
... context
.... encounter S0..1Reference(MediRecords Core Encounter)Context of the document content

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceThis is an abstract profile
A 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.


.... 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(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)MediRecords 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(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient | MediRecords Core PractitionerRole)Document recipient
Slice: Unordered, Closed by type:$this
..... value[x]:valueReference 1..1Reference(MediRecords Core Practitioner | MediRecords Core Organisation | MediRecords Core Patient)Document recipient
... documentTitle S0..1stringMediRecords 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 SΣC0..1codeIndicates if the document is Unchecked (preliminary) or Checked (final)
Binding: CompositionStatus (required): Status of the underlying document.


inv-mr-docref-in-docstatus-01: MediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
... type SΣ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..1CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(MediRecords Core Patient)Who/what is the subject of the document
... date SΣ0..1instantWhen this document reference was created
... author SΣ0..1Reference(MediRecords Core Practitioner | MediRecords Core PractitionerRole | MediRecords Core Organisation)Who and/or what authored the document
... authenticator S0..1Reference(MediRecords Core Practitioner)The user from the practice who checked the document on upload
... custodian S1..1Reference(MediRecords Core 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: 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 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(MediRecords Core 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

PathConformanceValueSet
DocumentReference.meta.securityextensibleAll Security Labels
DocumentReference.meta.tagexampleCommonTags
DocumentReference.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Max Binding: AllLanguages
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePathDetailsRequirements
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-docref-in-docstatus-01errorDocumentReference.docStatusMediRecords supports only preliminary - 'This is a preliminary composition or document. The content may be incomplete or unverified' or final- 'This version of the composition is complete and verified by an appropriate person and no further work is planned'
: $this.exists() implies ($this = 'preliminary' or $this = 'final')