TELUS DW Generic FHIR Extract

DwDocumentReferenceClinicalNote

Purpose

This resource will provide the clinical documentation from an interatction between the patient and a healthcare provider. Structured as the full note as displayed within the EMR

DocumentReference	I		DocumentReference	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 DocumentReference 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
id	Σ	1..1	string	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 string
meta	Σ	0..1	Meta	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 Meta 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
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.meta.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.meta.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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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
versionId	Σ	0..1	id	There are no (further) constraints on this element Element id DocumentReference.meta.versionId Short description Version specific identifier Definition The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted. Comments The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes. Data type id Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
lastUpdated	Σ	1..1	instant	There are no (further) constraints on this element Element id DocumentReference.meta.lastUpdated Short description When the resource version last changed Definition When the resource last changed - e.g. when the version changed. Comments This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction. Data type instant Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
source	Σ	1..1	uri	There are no (further) constraints on this element Element id DocumentReference.meta.source Short description Identifies where the resource comes from Definition A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc. Comments In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
profile	Σ	0..*	canonical(StructureDefinition)	There are no (further) constraints on this element Element id DocumentReference.meta.profile Short description Profiles this resource claims to conform to Definition A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url. Comments It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set. Data type canonical(StructureDefinition) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
security	Σ	0..*	CodingBinding	There are no (further) constraints on this element Element id DocumentReference.meta.security Short description Security Labels applied to this resource Definition Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure. Comments The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) 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
tag	Σ	0..*	Coding	There are no (further) constraints on this element Element id DocumentReference.meta.tag Short description Tags applied to this resource Definition Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource. Comments The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored. Data type Coding Binding Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". CommonTags (example) 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
implicitRules	Σ ?!	0..1	uri	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 uri 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 code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
text		1..1	Narrative	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 Narrative 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..*	Resource	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 Resource Mappings rim: Entity. Role, or Act rim: N/A
extension	I	0..*	Extension	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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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	?! I	0..*	Extension	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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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	Σ	0..1	Identifier	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 Identifier 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	Σ	1..1	Identifier	There are no (further) constraints on this element Element id DocumentReference.identifier Short description Other identifiers for the document Definition Other identifiers associated with the document, including version independent identifiers. Data type Identifier 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	There are no (further) constraints on this element Element id DocumentReference.status Short description current \| superseded \| entered-in-error Definition 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 code Binding The status of the document reference. DocumentReferenceStatus (required) 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	S Σ	0..1	codeBinding	Element id DocumentReference.docStatus Short description preliminary \| final \| amended \| entered-in-error Definition The status of the underlying document. Comments Usage note: Unsigned note/blue bar/unfinished note --> preliminary signed note/no blue bar --> final deleted note --> entered-in-error modified note --> amended The document that is pointed to might be in various lifecycle states. Data type code Binding Status of the underlying document. CompositionStatus (required) 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	S Σ	0..1	CodeableConceptBinding	Element id DocumentReference.type Short description Kind of document (LOINC if possible) Definition 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 Usage note: Use Loinc code 11506-3 Progress note 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 CodeableConcept Binding Precise type of clinical document. DocumentTypeValueSet (preferred) 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.
category	Σ	0..*	CodeableConcept	There are no (further) constraints on this element Element id DocumentReference.category Short description Categorization of document Alternate names claxs Definition 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 CodeableConcept Binding High-level kind of a clinical document at a macro level. DocumentClassValueSet (example) 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 I	1..1	Reference(Patient \| Practitioner \| Group \| Device)	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(Patient \| Practitioner \| Group \| Device) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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	S Σ	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 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 I	1..1	Reference(Practitioner \| PractitionerRole \| Organization \| Device \| Patient \| RelatedPerson)	There are no (further) constraints on this element Element id DocumentReference.author Short description Who and/or what authored the document Definition 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(Practitioner \| PractitionerRole \| Organization \| Device \| Patient \| RelatedPerson) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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	I	0..1	Reference(Practitioner \| PractitionerRole \| Organization)	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(Practitioner \| PractitionerRole \| Organization) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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	I	0..1	Reference(Organization)	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 Reference(Organization) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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	Σ	0..*	BackboneElement	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 BackboneElement 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
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.relatesTo.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.relatesTo.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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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 ?! I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.relatesTo.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 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 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 Extension 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
code	Σ	1..1	codeBinding	There are no (further) constraints on this element Element id DocumentReference.relatesTo.code Short description replaces \| transforms \| signs \| appends Definition The type of relationship that this document has with anther document. Comments If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. Data type code Binding The type of relationship between documents. DocumentRelationshipType (required) 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.code rim: .outboundRelationship.typeCode xds: DocumentEntry Associations type
target	Σ I	1..1	Reference(DocumentReference)	There are no (further) constraints on this element Element id DocumentReference.relatesTo.target Short description Target of the relationship Definition The target document of this relationship. 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(DocumentReference) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) fhircomposition: Composition.relatesTo.target rim: .target[classCode="DOC", moodCode="EVN"].id xds: DocumentEntry Associations reference
description	Σ	0..1	string	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 string 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	Σ	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 CodeableConcept Binding Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) 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	Σ	1..*	BackboneElement	There are no (further) constraints on this element Element id DocumentReference.content Short description Document referenced Definition The document and format referenced. There may be multiple content element repetitions, each with a different format. Data type BackboneElement 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
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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 ?! I	0..*	Extension	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 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 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 Extension 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 I	1..1	Attachment	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 Attachment 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
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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	S Σ	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 code Binding The mime type of an attachment. Any valid mime type is allowed. Mime Types (required) 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	Σ	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 code Binding A human language. CommonLanguages (preferred) 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		1..1	base64Binary	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 base64Binary 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	Σ	0..1	url	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 url 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	S Σ	0..1	unsignedInt	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 unsignedInt 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	S Σ	0..1	base64Binary	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 base64Binary 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	S Σ	0..1	string	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 Usage note: MA - provide the title of the template prefixed with "visit" PSS - Provide title as "Progress note". If it is categorized note also provide the category where avaiable eg "progress note - 'category name'" Note that FHIR strings SHALL NOT exceed 1MB in size Data type string 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	S Σ	0..1	dateTime	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 dateTime 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	Σ	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 Coding Binding Document Format Codes. DocumentReferenceFormatCodeSet (preferred) 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	Σ	0..1	BackboneElement	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 BackboneElement 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']
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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 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 Extension Sliced: Unordered, Open, by url(Value) Extensions are always sliced by (at least) url 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 ?! I	0..*	Extension	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 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 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 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 Extension 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	S I	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 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(Encounter \| EpisodeOfCare) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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..*	CodeableConcept	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 CodeableConcept Binding This list of codes represents the main clinical acts being documented. v3.ActCode (example) 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 I	0..1	Period	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 Period 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..1	CodeableConcept	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 CodeableConcept Binding XDS Facility Type. FacilityTypeCodeValueSet (example) 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..1	CodeableConcept	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 CodeableConcept Binding Additional details about where the content was created (e.g. clinical specialty). PracticeSettingCodeValueSet (example) 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	I	0..1	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 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(Patient) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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/
related	I	0..*	Reference(Resource)	There are no (further) constraints on this element 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(Resource) 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.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` 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

Usage note

.type these clinical notes will be identified with the Loinc code 11506-3 for Progress note.

Bundle

DwDocumentRefClinicalNote

Example

{
      "resourceType": "DocumentReference",
      "id": "pss-CDK5-DocumentReference-5745454",
      "meta": {
         "source": "urn:telus:emr:pss:CDK5",
         "lastUpdated": "2023-05-05T12:52:45.000Z",
         "security": [
            {
               "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
               "code": "N",
               "display": "normal"
            }
         ]
      },
      "identifier": [
         {
            "system": "urn:telus:emr:pss:CDK5:DocumentReference",
            "use": "usual",
            "value": "5745454"
         }
      ],
      "status": "current",
      "type": {
         "coding": [
            {
               "system": "http://loinc.org",
               "code": "11506-3",
               "display": "Progress Note"
            }
         ]
      },
      "category": [],
      "subject": {
         "reference": "Patient/pss-CDK5-Patient-93277",
         "type": "Patient"
      },
      "date": "2023-04-04T04:00:00.000Z",
      "author": [
         {
            "reference": "Practitioner/pss-CDK5-Practitioner-15",
            "display": "Dr. Hanna Hook MD",
            "type": "Practitioner"
         }
      ],
      "content": [
         {
            "attachment": {
               "contentType": "text/plain; charset=utf-8",
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      "context": {
         "encounter": [
            {
               "reference": "Encounter/pss-CDK5-Encounter-5745454",
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