This draft implementation guidance was developed between February and March 2023 as part of the NHS England Virtual Wards Interoperability Discovery. It is provided for information only and is not currently being updated.

If you are not participating in the Discovery, you are advised not to develop against this guidance until a formal announcement has been made. The team can be contacted by emailing england.virtualward.interoperability@nhs.net.

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3.4.5 FHIR UK Core DocumentReference Profile

IMPORTANT – The UK Core DocumentReference profile is currently in draft status and has not undergone Clinical & Technical Assurance review, or been part of the HL7 UK Ballot process. This profile may change in future releases of the UK Core.

IMPORTANT - this page is intended as guidance only, solutions must be clinically assured locally within organisations before deployment into a live environment.

Usage

The DocumentReference resource is used to represent a document of any kind, such as a clinical document, lab report, or imaging study, that is stored electronically. The resource includes metadata about the document, such as its title, author, and creation date, as well as a reference to the actual document content, which can be stored in a variety of formats, including PDF. The DocumentReference resource is part of the FHIR standard and is used to facilitate the exchange of electronic documents between different systems and organizations.

Structure Definition

https://simplifier.net/Simplifier.Core.R4.Resources/DocumentReference/~json

Optionality Guidance

The population guidance below uses the following definitions for data item optionality:

  1. Mandatory - the data item MUST be recorded in the resource every time it is produced
  2. Required - if the system that is providing the data item contains this piece of data, then it should include it in the resource
  3. Optional - the system has the option to include this data if it is available

Note that the population guidance for this profile does not include all data items available in the resource. As per FHIR guidance, all data items inherited from the base resource can be included and used as appropriate, however only those considered relevant to Supplementary RM Data are covered in this guidance.

Required Elements (for Supplementary RM Data)

A minimum viable content that all provider and consumer systems should support is the following elements.

Element Optionality
DocumentReference.id Mandatory
DocumentReference.meta Mandatory
DocumentReference.masterIdentifier Mandatory
DocumentReference.status Mandatory
DocumentReference.docStatus Optional
DocumentReference.type Required
DocumentReference.subject Mandatory
DocumentReference.author Optional
DocumentReference.custodian Mandatory
DocumentReference.content Mandatory
DocumentReference.context Optional

Id

FHIR Attribute DataType Optionality Cardinality Usage Guidance
id id Mandatory 1:1 A logical identifier generated for this document reference resource. Additional Guidance: Any combination of upper- or lower-case ASCII letters ('A'..'Z', and 'a'..'z', numerals ('0'..'9'), '-' and '.', with a length limit of 64 characters. (This might be an integer, an un-prefixed OID, UUID or any other identifier pattern that meets these constraints.)

Example

{
    "id": "eeef5be5-30c5-4d0a-aecc-91b5648e9c9f"
}

Meta

FHIR Attribute DataType Optionality Cardinality Usage Guidance
Meta Element Mandatory 1:1 Metadata about the resource
meta.profile Canonical Mandatory 1:1 To identify the FHIR profile the resource conforms to Fixed value: "https://fhir.hl7.org.uk/StructureDefinition/UKCore-DocumentReference"

Example

"meta": {
    "profile": [
        "https://fhir.hl7.org.uk/StructureDefinition/UKCore-DocumentReference"
    ]
}

DocumentReference.masterIdentifier

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.masterIdentifier Identifier Mandatory 0:1 Master Version Specific Identifier Local identifier for the document, for tracing and audit purposes
DocumentReference.masterIdentifier.System uri Mandatory 1:1 Establishes namespace for the value
DocumentReference.masterIdentifier.Value String Mandatory 1:1 The identifier value that is unique

Example

"masterIdentifier": {
    "system": "http://example.com/identifiers",
    "value": "12345"
}

DocumentReference.Status

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.masterIdentifier.Status Code Mandatory 1:1 The status of this document reference. Fixed value: "current".

Example

"status": "current"

DocumentReference.docStatus

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.docStatus CodeableConcept Optional 0:1 The status of this document reference. "preliminary | final | amended | entered-in-error" For Supplementary RM Data, the value should be "current".

Example

"docStatus": "final"

DocumentReference.type

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Type CodeableConcept Required 0:1 Kind of document (SNOMED CT if possible) Should be used if an appropriate code to represent the document is available.

Example

    "type": {
        "coding":  [
            {
                "system": "http://snomed.info/sct",
                "code": "371534008",
                "display": "Summary report (record artifact)"
            }
        ]
    }

DocumentReference.subject

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Subject Reference (UK Core Patient) Mandatory 1:1 Who the subject of the document is This must reference the patient resource included in the Bundle
DocumentReference.Subject.Reference String Mandatory 1:1 A reference to a location at which the Patient resource is found. A reference to Patient.id for the Patient resource in the Bundle.

Example

"subject" : {
    "reference": "urn:uuid:dd9724d1-7b61-44e2-9023-b72e6b966018-76563212455590986546"
}

DocumentReference.author

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Author Reference(UK Core Organization) Optional 0:* The organisation(s) that authored the document.
DocumentReference.Author.Reference String Required if using 0:1 A reference to a location at which the Organization resource is found. This should reference an Organization resource within the Bundle using the Organization.id field.

Example

"author:": [
    {
        "reference": "urn:uuid:9b9dfe0d-1747-424f-a739-35f7be8e8d71"
    }
]

DocumentReference.custodian

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Custodian Reference(UK Core Organization) Mandatory 1:1 Organisation which owns and maintains the document This should be the healthcare provider organisation sharing the data
DocumentReference.Custodian.Reference String Mandatory 1:1 A reference to a location at which the Organization resource is found. A reference to a location at which the Organization resource is found. This should reference an Organization resource within the Bundle using the Organization.id field.

Example

"custodian:": {
    "reference": "urn:uuid:9b9dfe0d-1747-424f-a739-35f7be8e8d71"
}

DocumentReference.content

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Content BackboneElement Mandatory 1:* The document referenced and the document metadata There may be multiple content element repetitions, each with a different format. PDF format must be included at minimum.
DocumentReference.Content.Attachment Attachment Mandatory 1:1 The document along with critical metadata to prove content has integrity.
DocumentReference.Content.Attachment.Title String Optional 0:1 A label or set of text to name the document If a DocumentReference.type code is not provided, this field must be provided.
DocumentReference.content.attachment.Data base64binary Mandatory 1:1 The actual data of the attachment - a sequence of bytes, base64 encoded. The Supplementary RM Data PDF document - a sequence of bytes, base64 encoded. The data needs to able to be transmitted inline. The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.
DocumentReference.content.attachment.ContentType code Mandatory 1:1 Mime type of the content, with charset etc. Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate. This should be "application/pdf"
DocumentReference.content.attachment.Creation dateTime Mandatory 1:1 The date that the attachment was created.

Example

"content":  [
        {
            "attachment": {
                "contentType": "application/pdf",
                "data": //base64encoded PDF,
                "title": "Care Plan Report",
                "creation": "2016-03-08T15:26:00+01:00"
            }
        }
    ]

DocumentReference.context

FHIR Attribute DataType Optionality Cardinality Usage Guidance
DocumentReference.Context BackboneElement Optional 0:1 The clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents.
DocumentReference.Context.Encounter Reference(UK Core Encounter) Optional 0:1 Context of the document content Describes the clinical encounter or type of care that the document content is associated with
DocumentReference.Context.Encounter.Reference String Optional 0:1 Literal reference, Relative, internal or absolute URL. This should reference an Encounter resource within the Bundle using the Encounter.id field.

Example

  "context": {
        "encounter": {
            "reference": "urn:uuid:4f28e0c6-17d6-4f52-b0a6-3bb88b1f6c9e"
        }
    }

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