SADIE Developer and Tester Guide

There are no (further) constraints on this element

Element id

DocumentReference

Short description

A reference to a document

Definition

A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

Comments

Usually, this is used for documents other than those defined by FHIR.

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: 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-3: 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-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
fhircomposition: when describing a Composition
rim: Document[classCode="DOC" and moodCode="EVN"]
cda: when describing a CDA

0..1

There are no (further) constraints on this element

Element id

DocumentReference.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

DocumentReference.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

DocumentReference.implicitRules

Short description

A set of rules under which this content was created

Definition

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Comments

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Comments

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

DocumentReference.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

Comments

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

masterIdentifier

0..0

There are no (further) constraints on this element

Element id

DocumentReference.masterIdentifier

Short description

Master Version Specific Identifier

Definition

Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.

Requirements

The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

Comments

CDA Document Id extension and root.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
fhircomposition: Composition.identifier
v2: TXA-12
rim: .id
xds: DocumentEntry.uniqueId
cda: ClinicalDocument/id

identifier

0..*

Element id

DocumentReference.identifier

Short description

`FOR SADIE USE: These are the client identifiers that will be used by the search. For ODSP this will be the Referral ID and Membership ID.`

Other identifiers associated with the document, including version independent identifiers.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
v2: TXA-16?
rim: .id / .setId
xds: DocumentEntry.entryUUID

status

Σ ?!

1..1

codeBinding

Element id

DocumentReference.status

Short description

current | superseded | entered-in-error

Definition

`FOR SADIE USE: Required. current = active.`

The status of this document reference.

Comments

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

Data type

DocumentReferenceStatus (required)

Binding

The status of the document reference.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
v2: TXA-19
rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
xds: DocumentEntry.availabilityStatus

docStatus

0..0

codeBinding

Element id

DocumentReference.docStatus

Short description

preliminary | final | amended | entered-in-error

Definition

`FOR SADIE USE: Might want to use this record the fact the code was used to create a request.`

The status of the underlying document.

Comments

The document that is pointed to might be in various lifecycle states.

Data type

Binding

Status of the underlying document.

CompositionStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.status
fhircomposition: Composition.status
v2: TXA-17
rim: .statusCode

type

0..1

CodeableConceptBinding

Element id

DocumentReference.type

Short description

Kind of document (LOINC if possible)

Definition

`FOR SADIE USE: This would link to ValueSet, it will only have one entry to start ODSP-Referral-Load`

Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Comments

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

Data type

DocumentTypeValueSet (preferred)

Binding

Precise type of clinical document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
fhircomposition: Composition.type
v2: TXA-2
rim: ./code
xds: DocumentEntry.type
cda: ClinicalDocument/code/@code The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.

`FOR SADIE USE: This would link to ValueSet, it will only have one entry to start ODSP-Referral-Load`

A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

Comments

Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

Data type

DocumentClassValueSet (example)

Binding

High-level kind of a clinical document at a macro level.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
w5: FiveWs.class
fhircomposition: Composition.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
xds: DocumentEntry.class
cda: Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code

subject

Σ C

0..0

Reference(Device | Group | Patient | Practitioner)

There are no (further) constraints on this element

Element id

DocumentReference.subject

Short description

Who/what is the subject of the document

Definition

Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

Comments

References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.

Data type

Reference(Device | Group | Patient | Practitioner)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.subject
w5: FiveWs.subject[x]
fhircomposition: Composition.subject
v2: PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
xds: DocumentEntry.patientId
cda: ClinicalDocument/recordTarget/
w5: FiveWs.subject

date

0..1

instant

There are no (further) constraints on this element

Element id

DocumentReference.date

Short description

When this document reference was created

Alternate names

indexed

Definition

When the document reference was created.

Comments

Referencing/indexing time is used for tracking, organizing versions and searching.

Data type

instant

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
workflow: Event.occurrence[x]
w5: FiveWs.recorded
fhircomposition: Composition.date
rim: .availabilityTime[type="TS"]

author

Σ C

0..*

Reference(ProgramArea)

Element id

DocumentReference.author

Short description

Who and/or what authored the document

Definition

`FOR SADIE USE: Reference to the client`

Identifies who is responsible for adding the information to the document.

Comments

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

Data type

Reference(ProgramArea)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
fhircomposition: Composition.author
v2: TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
xds: DocumentEntry.author
cda: ClinicalDocument/author

authenticator

0..0

Reference(Organization | Practitioner | PractitionerRole)

There are no (further) constraints on this element

Element id

DocumentReference.authenticator

Short description

Who/what authenticated the document

Definition

Which person or organization authenticates that this document is valid.

Comments

Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.

Data type

Reference(Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.witness
fhircomposition: Composition.attester
v2: TXA-10
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
xds: DocumentEntry.legalAuthenticator
cda: ClinicalDocument/legalAuthenticator

custodian

0..0

There are no (further) constraints on this element

Element id

DocumentReference.custodian

Short description

Organization which maintains the document

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Comments

Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
fhircomposition: Composition.custodian
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]

relatesTo

0..0

Element id

DocumentReference.relatesTo

Short description

Relationships to other documents

Definition

`FOR SADIE USE: Reference to the DocumentReference the client sent.`

Relationships that this document has with other document references that already exist.

Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
fhircomposition: Composition.relatesTo
rim: .outboundRelationship
xds: DocumentEntry Associations

description

0..0

There are no (further) constraints on this element

Element id

DocumentReference.description

Short description

Human-readable description

Definition

Human-readable description of the source document.

Requirements

Helps humans to assess whether the document is of interest.

Comments

What the document is about, a terse summary of the document.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: TXA-25
rim: .outboundRelationship[typeCode="SUBJ"].target.text
xds: DocumentEntry.comments

securityLabel

0..0

CodeableConceptBinding

There are no (further) constraints on this element

Element id

DocumentReference.securityLabel

Short description

Document security-tags

Definition

A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.

Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Comments

The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
fhircomposition: Composition.confidentiality, Composition.meta.security
v2: TXA-18
rim: .confidentialityCode
xds: DocumentEntry.confidentialityCode
cda: ClinicalDocument/confidentialityCode/@code

content

1..*

Element id

DocumentReference.content

Short description

Document referenced

Definition

`FOR SADIE USE: This is required but if it's just the two IDs then just create attachment with only a title 'No Attachment'. If in the future they add the patient names then that would go in the data OR all the information can go in the data including the IDs so a function can generically pro cess it.`

The document and format referenced. There may be multiple content element repetitions, each with a different format.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
fhircomposition: Bundle(Composition+*)
rim: document.text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

attachment

Σ C

1..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment

Short description

Where to access the document

Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Comments

When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
att-1: If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()

Mappings

rim: n/a
v2: ED/RP
rim: ED
fhircomposition: Composition.language, Composition.title, Composition.date
v2: TXA-3 for mime type
rim: document.text
xds: DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
cda: ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

contentType

0..1

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.contentType

Short description

Mime type of the content, with charset etc.

Definition

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.

Requirements

Processors of the data need to be able to know how to interpret the data.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The mime type of an attachment. Any valid mime type is allowed.

Mime Types (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

text/plain; charset=UTF-8, image/png

Mappings

rim: n/a
v2: ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
rim: ./mediaType, ./charset

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.language

Short description

Human language of the content (BCP-47)

Definition

The human language of the content. The value can be any valid value according to BCP 47.

Requirements

Users need to be able to choose between the languages in a set of attachments.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

en-AU

Mappings

rim: n/a
rim: ./language

data

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.data

Short description

Data inline, base64ed

Definition

The actual data of the attachment - a sequence of bytes, base64 encoded.

Requirements

The data needs to able to be transmitted inline.

Comments

The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: ED.5
rim: ./data

url

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.url

Short description

Uri where the data can be found

Definition

A location where the data can be accessed.

Requirements

The data needs to be transmitted by reference.

Comments

If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/logo-small.png

Mappings

rim: n/a
v2: RP.1+RP.2 - if they refer to a URL (see v2.6)
rim: ./reference/literal

size

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.size

Short description

Number of bytes of content (if url provided)

Definition

The number of bytes of data that make up this attachment (before base64 encoding, if that is done).

Requirements

Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.

Comments

The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A (needs data type R3 proposal)

hash

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.hash

Short description

Hash of the data (sha-1, base64ed)

Definition

The calculated hash of the data using SHA-1. Represented using base64.

Requirements

Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).

Comments

The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see Provenance.signature for mechanism to protect a resource with a digital signature.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"]

title

0..1

Element id

DocumentReference.content.attachment.title

Short description

Label to display in place of the data

Definition

`FOR SADIE USE: For ODSP either leave it completely empty of set this to No Attachment`

A label or set of text to display in place of the data.

Requirements

Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Official Corporate Logo

Mappings

rim: n/a
rim: ./title/data

creation

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.creation

Short description

Date attachment was first created

Definition

The date that the attachment was first created.

Requirements

This is often tracked as an integrity issue for use of the attachment.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A (needs data type R3 proposal)

format

0..1

CodingBinding

There are no (further) constraints on this element

Element id

DocumentReference.content.format

Short description

Format/content rules for the document

Definition

An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Comments

Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

Data type

DocumentReferenceFormatCodeSet (preferred)

Binding

Document Format Codes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
rim: CV
orim: fhir:Coding rdfs:subClassOf dt:CDCoding
fhircomposition: Composition.meta.profile
rim: document.text
xds: DocumentEntry.formatCode
cda: derived from the IHE Profile or Implementation Guide templateID

context

0..1

Element id

DocumentReference.context

Short description

Clinical context of document

Definition

`FOR SADIE USE: This is a reference to the client communication record.`

The clinical context in which the document was prepared.

Comments

These values are primarily added to help with searching for interesting/relevant documents.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

encounter

0..0

Reference(Encounter | EpisodeOfCare)

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter

Short description

Context of the document content

Definition

Describes the clinical encounter or type of care that the document content is associated with.

Comments

Data type

Reference(Encounter | EpisodeOfCare)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.context
w5: FiveWs.context
fhircomposition: Composition.encounter
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])

event

0..0

There are no (further) constraints on this element

Element id

DocumentReference.context.event

Short description

Main clinical acts documented

Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Comments

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

Data type

Binding

This list of codes represents the main clinical acts being documented.

v3.ActCode (example)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
fhircomposition: Composition.event.code
rim: .code
xds: DocumentEntry.eventCodeList

period

Σ C

0..0

There are no (further) constraints on this element

Element id

DocumentReference.context.period

Short description

Time of service that is being documented

Definition

The time period over which the service that is described by the document was provided.

Comments

A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times").

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)

Mappings

rim: n/a
v2: DR
rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
fhircomposition: Composition.event.period
rim: .effectiveTime
xds: DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
cda: ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value

facilityType

0..0

There are no (further) constraints on this element

Element id

DocumentReference.context.facilityType

Short description

Kind of facility where patient was seen

Definition

The kind of facility where the patient was seen.

Comments

Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.

Data type

FacilityTypeCodeValueSet (example)

Binding

XDS Facility Type.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
fhircomposition: usually from a mapping to a local ValueSet
rim: .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
xds: DocumentEntry.healthcareFacilityTypeCode
cda: usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code

practiceSetting

0..0

There are no (further) constraints on this element

Element id

DocumentReference.context.practiceSetting

Short description

Additional details about where the content was created (e.g. clinical specialty)

Definition

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Comments

This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

Data type

PracticeSettingCodeValueSet (example)

Binding

Additional details about where the content was created (e.g. clinical specialty).

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
fhircomposition: usually from a mapping to a local ValueSet
rim: .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
xds: DocumentEntry.practiceSettingCode
cda: usually from a mapping to a local ValueSet

sourcePatientInfo

0..0

Reference(Patient)

There are no (further) constraints on this element

Element id

DocumentReference.context.sourcePatientInfo

Short description

Patient demographics from source

Definition

The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Comments

Data type

Reference(Patient)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
fhircomposition: Composition.subject
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
xds: DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
cda: ClinicalDocument/recordTarget/

1..1

Reference(Client Communication)

Element id

DocumentReference.context.related

Short description

Related identifiers or resources

Definition

Related identifiers or resources associated with the DocumentReference.

Comments

May be identifiers or resources that caused the DocumentReference or referenced Document to be created.

Data type

Reference(Client Communication)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
fhircomposition: Composition.event.detail
rim: ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
xds: DocumentEntry.referenceIdList
cda: ClinicalDocument/relatedDocument

Example - ODSP Referral Record

Command 'json' could not render: File not found for 'subject=Example-ODSP-Referral-Record'

Request PDF

The application generates a PDF version of a request, this is how it is stored.

Requirements

to do

Profile - Request PDF

RequestPDF (DocumentReference)

Element id

DocumentReference

Short description

A reference to a document

Definition

Comments

`FOR SADIE USE: This is used to store the PDF version of the Request.`

Usually, this is used for documents other than those defined by FHIR.

Data type

Constraints

dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
contained.contained.empty()
dom-4: 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-3: 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-6: A resource should have narrative for robust management
text.`div`.exists()
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
contained.meta.security.empty()

Mappings

rim: Entity. Role, or Act
workflow: Event
fhircomposition: when describing a Composition
rim: Document[classCode="DOC" and moodCode="EVN"]
cda: when describing a CDA

0..1

There are no (further) constraints on this element

Element id

DocumentReference.id

Short description

Logical id of this artifact

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

There are no (further) constraints on this element

Element id

DocumentReference.meta

Short description

Metadata about the resource

Definition

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A

implicitRules

Σ ?!

0..1

There are no (further) constraints on this element

Element id

DocumentReference.implicitRules

Short description

A set of rules under which this content was created

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

language

0..1

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.language

Short description

Language of the resource content

Definition

The base language in which the resource is written.

Comments

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a

text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.text

Short description

Text summary of the resource, for human interpretation

Alternate names

narrative, html, xhtml, display

Definition

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A
rim: Act.text?

contained

0..*

There are no (further) constraints on this element

Element id

DocumentReference.contained

Short description

Contained, inline Resources

Alternate names

inline resources, anonymous resources, contained resources

Definition

Comments

Data type

Mappings

rim: Entity. Role, or Act
rim: N/A

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.modifierExtension

Short description

Extensions that cannot be ignored

Alternate names

extensions, user content

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

masterIdentifier

0..0

There are no (further) constraints on this element

Element id

DocumentReference.masterIdentifier

Short description

Master Version Specific Identifier

Definition

Requirements

Comments

CDA Document Id extension and root.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
fhircomposition: Composition.identifier
v2: TXA-12
rim: .id
xds: DocumentEntry.uniqueId
cda: ClinicalDocument/id

identifier

0..*

Element id

DocumentReference.identifier

Short description

`FOR SADIE USE: This is an identifier the client gives to this request pdf.`

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CX / EI (occasionally, more often EI maps to a resource id or a URL)
rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]
servd: Identifier
workflow: Event.identifier
w5: FiveWs.identifier
v2: TXA-16?
rim: .id / .setId
xds: DocumentEntry.entryUUID

0..1

There are no (further) constraints on this element

Element id

DocumentReference.identifier.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

use

Σ ?!

0..0

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.identifier.use

Short description

usual | official | temp | secondary | old (If known)

Definition

The purpose of this identifier.

Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: N/A
rim: Role.code or implied by context

type

0..0

CodeableConceptBinding

There are no (further) constraints on this element

Element id

DocumentReference.identifier.type

Short description

Description of identifier

Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

Data type

Identifier Type Codes (extensible)

Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
v2: CX.5
rim: Role.code or implied by context

system

1..1

uriBinding

Element id

DocumentReference.identifier.system

Short description

The namespace for the identifier value

Definition

`FOR SADIE USE: The system element is bound the to the FlexForms-IdentifierSystems Value Set`

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Comments

Identifier.system is always case sensitive.

Data type

FlexFormsIdentifierSystems (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/identifiers/patient

Mappings

rim: n/a
v2: CX.4 / EI-2-4
rim: II.root or Role.id.root
servd: ./IdentifierType

value

1..1

There are no (further) constraints on this element

Element id

DocumentReference.identifier.value

Short description

The value that is unique

Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Mappings

rim: n/a
v2: CX.1 / EI.1
rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
servd: ./Value

period

Σ C

0..0

There are no (further) constraints on this element

Element id

DocumentReference.identifier.period

Short description

Time period when id is/was valid for use

Definition

Time period during which identifier is/was valid for use.

Comments

Period is not used for a duration (a measure of elapsed time). See Duration.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
per-1: If present, start SHALL have a lower value than end
start.hasValue().not() or end.hasValue().not() or (start <= end)

Mappings

rim: n/a
v2: DR
rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"]
v2: CX.7 + CX.8
rim: Role.effectiveTime or implied by context
servd: ./StartDate and ./EndDate

assigner

Σ C

0..0

There are no (further) constraints on this element

Element id

DocumentReference.identifier.assigner

Short description

Organization that issued id (may be just text)

Definition

Organization that issued/manages the identifier.

Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
v2: CX.4 / (CX.4,CX.9,CX.10)
rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
servd: ./IdentifierIssuingAuthority

status

Σ ?!

1..1

codeBindingFixed Value

Element id

DocumentReference.status

Short description

current | superseded | entered-in-error

Definition

`FOR SADIE USE: This is a FHIR mandatory field , it should always be 'current'.`

The status of this document reference.

Comments

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

Data type

DocumentReferenceStatus (required)

Binding

The status of the document reference.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

current

Mappings

rim: n/a
workflow: Event.status
w5: FiveWs.status
v2: TXA-19
rim: interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
xds: DocumentEntry.availabilityStatus

docStatus

0..0

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.docStatus

Short description

preliminary | final | amended | entered-in-error

Definition

The status of the underlying document.

Comments

The document that is pointed to might be in various lifecycle states.

Data type

Binding

Status of the underlying document.

CompositionStatus (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
w5: FiveWs.status
fhircomposition: Composition.status
v2: TXA-17
rim: .statusCode

type

1..1

CodeableConceptBinding

Element id

DocumentReference.type

Short description

Kind of document (LOINC if possible)

Definition

`FOR SADIE USE: This has a fixed value of 'RequestPDF'`

Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Comments

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

Data type

DocumentTypeValueSet (preferred)

Binding

Precise type of clinical document.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
workflow: Event.code
w5: FiveWs.class
fhircomposition: Composition.type
v2: TXA-2
rim: ./code
xds: DocumentEntry.type
cda: ClinicalDocument/code/@code The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.

0..1

There are no (further) constraints on this element

Element id

DocumentReference.type.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.type.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

coding

0..*

There are no (further) constraints on this element

Element id

DocumentReference.type.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
rim: CV
orim: fhir:Coding rdfs:subClassOf dt:CDCoding
v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding

0..1

There are no (further) constraints on this element

Element id

DocumentReference.type.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.type.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

system

1..1

uriFixed Value

Element id

DocumentReference.type.coding.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

https://health.gov.on.ca/sadie/fhir/CodeSystem/FlexForms-Internal-Complete

Mappings

rim: n/a
v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..0

There are no (further) constraints on this element

Element id

DocumentReference.type.coding.version

Short description

Version of the system - if relevant

Definition

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Comments

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

0..1

codeBindingFixed Value

Element id

DocumentReference.type.coding.code

Short description

Symbol in syntax defined by the system

Definition

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Requirements

Need to refer to a particular code in the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

FlexFormsDocumentReferenceTypes (required)

Binding

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Fixed value

RequestPDF

Mappings

rim: n/a
v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..0

There are no (further) constraints on this element

Element id

DocumentReference.type.coding.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

userSelected

0..0

boolean

There are no (further) constraints on this element

Element id

DocumentReference.type.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

Comments

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

Data type

boolean

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: Sometimes implied by being first
rim: CD.codingRationale
orim: fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]

text

0..0

There are no (further) constraints on this element

Element id

DocumentReference.type.text

Short description

Plain text representation of the concept

Definition

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Requirements

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

`FOR SADIE USE: This is the Requestor Role that owns the related Request. This is used by the security interceptor.`

Comments

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

Data type

Reference(FlexFormsRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
fhircomposition: Composition.author
v2: TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
xds: DocumentEntry.author
cda: ClinicalDocument/author

authenticator

0..0

Reference(Organization | Practitioner | PractitionerRole)

There are no (further) constraints on this element

Element id

DocumentReference.authenticator

Short description

Who/what authenticated the document

Definition

Which person or organization authenticates that this document is valid.

Comments

Data type

Reference(Organization | Practitioner | PractitionerRole)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
w5: FiveWs.witness
fhircomposition: Composition.attester
v2: TXA-10
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
xds: DocumentEntry.legalAuthenticator
cda: ClinicalDocument/legalAuthenticator

custodian

0..0

There are no (further) constraints on this element

Element id

DocumentReference.custodian

Short description

Organization which maintains the document

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ref-1: SHALL have a contained resource if a local reference is provided
reference.exists() implies (reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids')) or (reference='#' and %rootResource!=%resource))

Mappings

rim: n/a
rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity)
workflow: Event.performer.actor
fhircomposition: Composition.custodian
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]

relatesTo

0..0

There are no (further) constraints on this element

Element id

DocumentReference.relatesTo

Short description

Relationships to other documents

Definition

Relationships that this document has with other document references that already exist.

Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
fhircomposition: Composition.relatesTo
rim: .outboundRelationship
xds: DocumentEntry Associations

description

0..0

There are no (further) constraints on this element

Element id

DocumentReference.description

Short description

Human-readable description

Definition

Human-readable description of the source document.

Requirements

Helps humans to assess whether the document is of interest.

Comments

What the document is about, a terse summary of the document.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: TXA-25
rim: .outboundRelationship[typeCode="SUBJ"].target.text
xds: DocumentEntry.comments

securityLabel

0..0

CodeableConceptBinding

There are no (further) constraints on this element

Element id

DocumentReference.securityLabel

Short description

Document security-tags

Definition

Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Comments

Data type

All Security Labels (extensible)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE
rim: CD
orim: fhir:CodeableConcept rdfs:subClassOf dt:CD
fhircomposition: Composition.confidentiality, Composition.meta.security
v2: TXA-18
rim: .confidentialityCode
xds: DocumentEntry.confidentialityCode
cda: ClinicalDocument/confidentialityCode/@code

content

1..1

Element id

DocumentReference.content

Short description

Document referenced

Definition

`FOR SADIE USE: This is the PDF'.`

The document and format referenced. There may be multiple content element repetitions, each with a different format.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
fhircomposition: Bundle(Composition+*)
rim: document.text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

attachment

Σ C

1..1

Element id

DocumentReference.content.attachment

Short description

Where to access the document

Definition

`FOR SADIE USE: This is the PDF'.`

The document or URL of the document along with critical metadata to prove content has integrity.

Comments

When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
att-1: If the Attachment has data, it SHALL have a contentType
data.empty() or contentType.exists()

Mappings

rim: n/a
v2: ED/RP
rim: ED
fhircomposition: Composition.language, Composition.title, Composition.date
v2: TXA-3 for mime type
rim: document.text
xds: DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
cda: ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a
rim: N/A

contentType

0..1

codeBinding

Element id

DocumentReference.content.attachment.contentType

Short description

Mime type of the content, with charset etc.

Definition

`FOR SADIE USE: For PDFs it's application/pdf.`

A location where the data can be accessed.

Requirements

Processors of the data need to be able to know how to interpret the data.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

The mime type of an attachment. Any valid mime type is allowed.

Mime Types (required)

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

text/plain; charset=UTF-8, image/png

Mappings

rim: n/a
v2: ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
rim: ./mediaType, ./charset

language

0..0

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.language

Short description

Human language of the content (BCP-47)

Definition

The human language of the content. The value can be any valid value according to BCP 47.

Requirements

Users need to be able to choose between the languages in a set of attachments.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Binding

A human language.

Binding extensions

maxValueSet	AllLanguages

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

en-AU

Mappings

rim: n/a
rim: ./language

data

0..0

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.data

Short description

Data inline, base64ed

Definition

The actual data of the attachment - a sequence of bytes, base64 encoded.

Requirements

The data needs to able to be transmitted inline.

Comments

The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: ED.5
rim: ./data

url

0..1

Element id

DocumentReference.content.attachment.url

Short description

Uri where the data can be found

Definition

`FOR SADIE USE: This is the URL of the Binary.`

A location where the data can be accessed.

Requirements

The data needs to be transmitted by reference.

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/logo-small.png

Mappings

rim: n/a
v2: RP.1+RP.2 - if they refer to a URL (see v2.6)
rim: ./reference/literal

size

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.size

Short description

Number of bytes of content (if url provided)

Definition

The number of bytes of data that make up this attachment (before base64 encoding, if that is done).

Requirements

Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.

Comments

The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A (needs data type R3 proposal)

hash

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.hash

Short description

Hash of the data (sha-1, base64ed)

Definition

The calculated hash of the data using SHA-1. Represented using base64.

Requirements

Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).

Comments

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: .integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"]

title

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.title

Short description

Label to display in place of the data

Definition

A label or set of text to display in place of the data.

Requirements

Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.

Comments

Note that FHIR strings SHALL NOT exceed 1MB in size

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Official Corporate Logo

Mappings

rim: n/a
rim: ./title/data

creation

0..0

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.creation

Short description

Date attachment was first created

Definition

The date that the attachment was first created.

Requirements

This is often tracked as an integrity issue for use of the attachment.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
rim: N/A (needs data type R3 proposal)

format

0..0

CodingBinding

There are no (further) constraints on this element

Element id

DocumentReference.content.format

Short description

Format/content rules for the document

Definition

An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Comments

Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

Data type

DocumentReferenceFormatCodeSet (preferred)

Binding

Document Format Codes.

Conditions

The cardinality or value of this element may be affected by these constraints: ele-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: n/a
v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6
rim: CV
orim: fhir:Coding rdfs:subClassOf dt:CDCoding
fhircomposition: Composition.meta.profile
rim: document.text
xds: DocumentEntry.formatCode
cda: derived from the IHE Profile or Implementation Guide templateID

context

0..0

There are no (further) constraints on this element

Element id

DocumentReference.context

Short description

Clinical context of document

Definition

The clinical context in which the document was prepared.

Comments

These values are primarily added to help with searching for interesting/relevant documents.

Data type