DataStandardsWales-DocumentReference

The DocumentReference resource profile is used to index a document, clinical note, or other binary object to make them available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be displayed to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized MIME type and that conforms to this definition.

The DataStandardsWales-DocumentReference profile is derived from the HL7 R4 DocumentReference. It defines additional rules for use within health and care organisations in Wales.

A direct link to the Data Standards Wales asset can be accessed here - Data Standards Wales Document Reference

Formal Views of Profile Content

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
digitalStatusC1..1Extension(code)
sourceSystemS C0..1Extension(Reference(DataStandardsWalesDevice))
versionR5S C0..1Extension(string)
attesterR5S C0..*Extension(Complex)
errorStatusS C0..1Extension(code)
errorActionC0..*Extension(Complex)
documentAttributeC0..*Extension(Complex)
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryS Σ0..*CodeableConceptBinding
subjectS Σ0..1Reference(DataStandardsWalesPatient | DataStandardsWalesPractitioner | Group | DataStandardsWalesDevice)
dateS Σ0..1instant
authorS Σ0..*Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesRelatedPerson)
authenticator0..0Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization)
custodianS0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
attachmentΣ1..1Attachment
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounter0..*Reference(DataStandardsWalesEncounter | EpisodeOfCare)
event0..*CodeableConcept
periodΣ0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfo0..0Reference(DataStandardsWalesPatient)
related0..*Reference(Resource | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesLocation)
idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
digitalStatusC1..1Extension(code)
sourceSystemS C0..1Extension(Reference(DataStandardsWalesDevice))
versionR5S C0..1Extension(string)
attesterR5S C0..*Extension(Complex)
errorStatusS C0..1Extension(code)
errorActionC0..*Extension(Complex)
documentAttributeC0..*Extension(Complex)
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryS Σ0..*CodeableConceptBinding
subjectS Σ0..1Reference(DataStandardsWalesPatient | DataStandardsWalesPractitioner | Group | DataStandardsWalesDevice)
dateS Σ0..1instant
authorS Σ0..*Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesRelatedPerson)
authenticator0..0Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization)
custodianS0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
attachmentΣ1..1Attachment
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounter0..*Reference(DataStandardsWalesEncounter | EpisodeOfCare)
event0..*CodeableConcept
periodΣ0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfo0..0Reference(DataStandardsWalesPatient)
related0..*Reference(Resource | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesLocation)
idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
digitalStatusC1..1Extension(code)
sourceSystemS C0..1Extension(Reference(DataStandardsWalesDevice))
versionR5S C0..1Extension(string)
attesterR5S C0..*Extension(Complex)
errorStatusS C0..1Extension(code)
errorActionC0..*Extension(Complex)
documentAttributeC0..*Extension(Complex)
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ0..1Period
assignerΣ0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ0..1CodeableConceptBinding
categoryS Σ0..*CodeableConceptBinding
subjectS Σ0..1Reference(DataStandardsWalesPatient | DataStandardsWalesPractitioner | Group | DataStandardsWalesDevice)
dateS Σ0..1instant
authorS Σ0..*Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesRelatedPerson)
authenticator0..0Reference(DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization)
custodianS0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
attachmentΣ1..1Attachment
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounter0..*Reference(DataStandardsWalesEncounter | EpisodeOfCare)
event0..*CodeableConcept
periodΣ0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfo0..0Reference(DataStandardsWalesPatient)
related0..*Reference(Resource | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesOrganization | DataStandardsWalesLocation)

Mandatory and Must Support Data Elements

Refer to the Mandatory and Must Support page for guidance on how these elements should be interpreted.

Each DocumentReference must have:

  1. A status
  2. A digital status
  3. One or more attachments as either a base 64 binary or a URL.

Each DocumentReference must support:

  1. One or more identifiers
  2. A document status
  3. An error status (applicable if document is entered in error)
  4. A type
  5. One or more categories
  6. A subject
  7. A date
  8. One or more authors
  9. One or more attesters
  10. A custodian
  11. One or more security labels
  12. A practice setting
  13. A source system
  14. A version

The DocumentReference.status field SHALL be populated with with one of the following values defined by the FHIR standard:

  • current
  • superseded
  • entered-in-error

The DocumentReference.extension.digitalStatus field SHALL be populated with with one of the following values defined by the FHIR standard:

  • born-digital-document
  • scanned-paper-document
  • unknown

Extensions

The extensions listed below allow a number of the data elements listed above to be supported where not currently supported by the FHIR standard: