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
- Snapshot View
- Differential View
- Hybrid View
- Examples
| DataStandardsWalesDocumentReference (DocumentReference) | C | DocumentReference | There are no (further) constraints on this element Element idDocumentReferenceShort description A reference to a document DefinitionA 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. Usually, this is used for documents other than those defined by FHIR.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDocumentReference.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDocumentReference.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDocumentReference.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDocumentReference.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 1..* | Extension | There are no (further) constraints on this element Element idDocumentReference.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| digitalStatus | C | 1..1 | Extension(code) | Element idDocumentReference.extension:digitalStatusShort description Document digital status Alternate namesextensions, user content DefinitionThe digital status of the document. Indicates whether the document was always digital or created from a paper original via scanning. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourceSystem | S C | 0..1 | Extension(Reference(DataStandardsWalesDevice)) | Element idDocumentReference.extension:sourceSystemShort description The source system for the document details. Alternate namesextensions, user content DefinitionThe system from which the document details were sourced to create the document reference. 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. Extension(Reference(DataStandardsWalesDevice)) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-SourceSystem ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionR5 | S C | 0..1 | Extension | Element idDocumentReference.extension:versionR5Short description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.version ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attesterR5 | S C | 0..* | Extension(Complex) | Element idDocumentReference.extension:attesterR5Short description Attests to accuracy of the document. Alternate namesextensions, user content DefinitionA participant who has authenticated the accuracy of the document. (Backport from FHIR R5.) 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.attester ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorStatus | S C | 0..1 | Extension(code) | Element idDocumentReference.extension:errorStatusShort description Document error status Alternate namesextensions, user content DefinitionAn extension to carry a descriptive code for the document error status e.g. potential-misfile. The error status can be used by systems to affect document handling and presentation e.g. watermarking. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorAction | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:errorActionShort description Document error action metadata. Alternate namesextensions, user content DefinitionThis extension provides outline data for an action performed as part of a document error workflow e.g. document misfile proposed. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorAction ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| documentAttribute | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:documentAttributeShort description Additional metadata for the document Alternate namesextensions, user content DefinitionAdditional metadata as applicable to the document type. This element should be used with care to avoid a proliferation of undefined metadata. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentAttribute ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| masterIdentifier | Σ | 0..0 | Identifier | There are no (further) constraints on this element Element idDocumentReference.masterIdentifierShort description Master Version Specific Identifier DefinitionDocument 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. 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.). CDA Document Id extension and root. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 0..* | Identifier | Element idDocumentReference.identifierShort description Other identifiers for the document DefinitionOther identifiers associated with the document, including version independent identifiers. Unordered, Open, by Slices provided for the different types of national identifiers issued by the Welsh Care Records Service. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsDocumentId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsDocumentIdShort description The WCRS DocumentId. DefinitionThe version-specific DocumentId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsDocumentId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-document-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsSupersessionSetId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsSupersessionSetIdShort description The WCRS DocumentSupersessionSetId. DefinitionThe version-independent DocumentSupersessionSetId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsSupersessionSetId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-supersession-set-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.statusShort description current | superseded | entered-in-error DefinitionThe status of this document reference. 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. The status of the document reference. DocumentReferenceStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| docStatus | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.docStatusShort description preliminary | final | amended | entered-in-error DefinitionThe status of the underlying document. The document that is pointed to might be in various lifecycle states. Status of the underlying document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | S Σ | 1..1 | CodeableConceptBinding | Element idDocumentReference.typeShort description Kind of document DefinitionSpecifies 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. 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. Precise type of clinical document. DataStandardsWalesDocumentType (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| category | S Σ | 1..* | CodeableConceptBinding | Element idDocumentReference.categoryShort description Categorization of document Alternate namesclaxs DefinitionA 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. 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. High-level kind of a clinical document at a macro level. DataStandardsWalesDocumentCategory (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 0..1 | Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) | Element idDocumentReference.subjectShort description Who/what is the subject of the document DefinitionWho 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). 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. Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| date | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDocumentReference.dateShort description When this document reference was created Alternate namesindexed DefinitionWhen the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| author | S Σ C | 0..* | Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) | Element idDocumentReference.authorShort description Who and/or what authored the document DefinitionIdentifies who is responsible for adding the information to the document. Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| authenticator | C | 0..0 | Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.authenticatorShort description Who/what authenticated the document DefinitionWhich person or organization authenticates that this document is valid. 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. Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| custodian | S C | 0..1 | Reference(DataStandardsWalesOrganization) | Element idDocumentReference.custodianShort description Organization which maintains the document DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the document. 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. Reference(DataStandardsWalesOrganization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| relatesTo | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.relatesToShort description Relationships to other documents DefinitionRelationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.relatesTo.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.relatesTo.codeShort description replaces | transforms | signs | appends DefinitionThe type of relationship that this document has with anther document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| target | Σ C | 1..1 | Reference(DataStandardsWalesDocumentReference) | Element idDocumentReference.relatesTo.targetShort description Target of the relationship DefinitionThe target document of this relationship. 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. Reference(DataStandardsWalesDocumentReference) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| description | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.descriptionShort description Human-readable description DefinitionHuman-readable description of the source document. Helps humans to assess whether the document is of interest. What the document is about, a terse summary of the document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| securityLabel | S Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.securityLabelShort description Document security-tags DefinitionA 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. Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| content | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contentShort description Document referenced DefinitionThe document and format referenced. There may be multiple content element repetitions, each with a different format. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attachment | Σ C | 1..1 | Attachment | There are no (further) constraints on this element Element idDocumentReference.content.attachmentShort description Where to access the document DefinitionThe document or URL of the document along with critical metadata to prove content has integrity. 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". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.attachment.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contentType | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.content.attachment.contentTypeShort description Mime type of the content, with charset etc. DefinitionIdentifies 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. Processors of the data need to be able to know how to interpret the data. Note that FHIR strings SHALL NOT exceed 1MB in size The mime type of an attachment. Any valid mime type is allowed. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General text/plain; charset=UTF-8, image/pngMappings
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| language | Σ | 0..1 | codeBinding | Element idDocumentReference.content.attachment.languageShort description Human language of the content DefinitionThe human language of the content. Within NHS Wales, the three character ISO 639-3 code should be used where possible e.g. "eng" for English, "cym" for Welsh. Users need to be able to choose between the languages in a set of attachments. ISO 639-3 is a subset of the BCP 47 standard. Note that FHIR strings SHALL NOT exceed 1MB in size A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General en-AUMappings
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| data | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.dataShort description Data inline, base64ed DefinitionThe actual data of the attachment - a sequence of bytes, base64 encoded. The data needs to able to be transmitted inline. The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| url | Σ | 0..1 | url | There are no (further) constraints on this element Element idDocumentReference.content.attachment.urlShort description Uri where the data can be found DefinitionA location where the data can be accessed. The data needs to be transmitted by reference. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/logo-small.pngMappings
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| size | Σ | 0..1 | unsignedInt | There are no (further) constraints on this element Element idDocumentReference.content.attachment.sizeShort description Number of bytes of content (if url provided) DefinitionThe number of bytes of data that make up this attachment (before base64 encoding, if that is done). Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| hash | Σ | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.hashShort description Hash of the data (sha-1, base64ed) DefinitionThe calculated hash of the data using SHA-1. Represented using base64. 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). 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| title | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.titleShort description Label to display in place of the data DefinitionA label or set of text to display in place of the data. 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. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General Official Corporate LogoMappings
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| creation | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idDocumentReference.content.attachment.creationShort description Date attachment was first created DefinitionThe date that the attachment was first created. This is often tracked as an integrity issue for use of the attachment. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| format | Σ | 0..1 | CodingBinding | Element idDocumentReference.content.formatShort description Format/content rules for the document DefinitionAn identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. This optional field is not part of the formal metadata standard for document submission in Wales. It should not be confused with mime type which is stored as content.attachment.contentType. Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. Document Format Codes. DocumentReferenceFormatCodeSet (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| context | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contextShort description Clinical context of document DefinitionThe clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.context.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| encounter | C | 0..* | Reference(EpisodeOfCare | DataStandardsWalesEncounter) | Element idDocumentReference.context.encounterShort description Context of the document content DefinitionDescribes the clinical encounter or type of care that the document content is associated with. 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. Reference(EpisodeOfCare | DataStandardsWalesEncounter) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| event | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.eventShort description Main clinical acts documented DefinitionThis 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. 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. This list of codes represents the main clinical acts being documented. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.context.periodShort description Time of service that is being documented DefinitionThe time period over which the service that is described by the document was provided. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| facilityType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.facilityTypeShort description Kind of facility where patient was seen DefinitionThe kind of facility where the patient was seen. 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. XDS Facility Type. FacilityTypeCodeValueSet (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| practiceSetting | S | 0..1 | CodeableConceptBinding | Element idDocumentReference.context.practiceSettingShort description Additional details about where the content was created (e.g. clinical specialty) DefinitionThis property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. 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. Additional details about where the content was created (e.g. clinical specialty). UKCorePracticeSettingCode (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourcePatientInfo | C | 0..0 | Reference(DataStandardsWalesPatient) | Element idDocumentReference.context.sourcePatientInfoShort description Patient demographics from source DefinitionThe Patient Information as known when the document was published. May be a reference to a version specific, or contained. 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. Reference(DataStandardsWalesPatient) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| related | C | 0..* | Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.context.relatedShort description Related identifiers or resources DefinitionRelated identifiers or resources associated with the DocumentReference. May be identifiers or resources that caused the DocumentReference or referenced Document to be created. Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| DataStandardsWalesDocumentReference (DocumentReference) | C | DocumentReference | There are no (further) constraints on this element Element idDocumentReferenceShort description A reference to a document DefinitionA 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. Usually, this is used for documents other than those defined by FHIR.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDocumentReference.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDocumentReference.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDocumentReference.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDocumentReference.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 1..* | Extension | There are no (further) constraints on this element Element idDocumentReference.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| digitalStatus | C | 1..1 | Extension(code) | Element idDocumentReference.extension:digitalStatusShort description Document digital status Alternate namesextensions, user content DefinitionThe digital status of the document. Indicates whether the document was always digital or created from a paper original via scanning. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourceSystem | S C | 0..1 | Extension(Reference(DataStandardsWalesDevice)) | Element idDocumentReference.extension:sourceSystemShort description The source system for the document details. Alternate namesextensions, user content DefinitionThe system from which the document details were sourced to create the document reference. 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. Extension(Reference(DataStandardsWalesDevice)) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-SourceSystem ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionR5 | S C | 0..1 | Extension | Element idDocumentReference.extension:versionR5Short description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.version ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attesterR5 | S C | 0..* | Extension(Complex) | Element idDocumentReference.extension:attesterR5Short description Attests to accuracy of the document. Alternate namesextensions, user content DefinitionA participant who has authenticated the accuracy of the document. (Backport from FHIR R5.) 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.attester ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorStatus | S C | 0..1 | Extension(code) | Element idDocumentReference.extension:errorStatusShort description Document error status Alternate namesextensions, user content DefinitionAn extension to carry a descriptive code for the document error status e.g. potential-misfile. The error status can be used by systems to affect document handling and presentation e.g. watermarking. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorAction | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:errorActionShort description Document error action metadata. Alternate namesextensions, user content DefinitionThis extension provides outline data for an action performed as part of a document error workflow e.g. document misfile proposed. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorAction ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| documentAttribute | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:documentAttributeShort description Additional metadata for the document Alternate namesextensions, user content DefinitionAdditional metadata as applicable to the document type. This element should be used with care to avoid a proliferation of undefined metadata. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentAttribute ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| masterIdentifier | Σ | 0..0 | Identifier | There are no (further) constraints on this element Element idDocumentReference.masterIdentifierShort description Master Version Specific Identifier DefinitionDocument 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. 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.). CDA Document Id extension and root. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 0..* | Identifier | Element idDocumentReference.identifierShort description Other identifiers for the document DefinitionOther identifiers associated with the document, including version independent identifiers. Unordered, Open, by Slices provided for the different types of national identifiers issued by the Welsh Care Records Service. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsDocumentId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsDocumentIdShort description The WCRS DocumentId. DefinitionThe version-specific DocumentId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsDocumentId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-document-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsSupersessionSetId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsSupersessionSetIdShort description The WCRS DocumentSupersessionSetId. DefinitionThe version-independent DocumentSupersessionSetId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsSupersessionSetId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-supersession-set-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.statusShort description current | superseded | entered-in-error DefinitionThe status of this document reference. 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. The status of the document reference. DocumentReferenceStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| docStatus | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.docStatusShort description preliminary | final | amended | entered-in-error DefinitionThe status of the underlying document. The document that is pointed to might be in various lifecycle states. Status of the underlying document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | S Σ | 1..1 | CodeableConceptBinding | Element idDocumentReference.typeShort description Kind of document DefinitionSpecifies 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. 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. Precise type of clinical document. DataStandardsWalesDocumentType (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| category | S Σ | 1..* | CodeableConceptBinding | Element idDocumentReference.categoryShort description Categorization of document Alternate namesclaxs DefinitionA 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. 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. High-level kind of a clinical document at a macro level. DataStandardsWalesDocumentCategory (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 0..1 | Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) | Element idDocumentReference.subjectShort description Who/what is the subject of the document DefinitionWho 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). 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. Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| date | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDocumentReference.dateShort description When this document reference was created Alternate namesindexed DefinitionWhen the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| author | S Σ C | 0..* | Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) | Element idDocumentReference.authorShort description Who and/or what authored the document DefinitionIdentifies who is responsible for adding the information to the document. Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| authenticator | C | 0..0 | Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.authenticatorShort description Who/what authenticated the document DefinitionWhich person or organization authenticates that this document is valid. 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. Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| custodian | S C | 0..1 | Reference(DataStandardsWalesOrganization) | Element idDocumentReference.custodianShort description Organization which maintains the document DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the document. 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. Reference(DataStandardsWalesOrganization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| relatesTo | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.relatesToShort description Relationships to other documents DefinitionRelationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.relatesTo.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.relatesTo.codeShort description replaces | transforms | signs | appends DefinitionThe type of relationship that this document has with anther document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| target | Σ C | 1..1 | Reference(DataStandardsWalesDocumentReference) | Element idDocumentReference.relatesTo.targetShort description Target of the relationship DefinitionThe target document of this relationship. 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. Reference(DataStandardsWalesDocumentReference) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| description | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.descriptionShort description Human-readable description DefinitionHuman-readable description of the source document. Helps humans to assess whether the document is of interest. What the document is about, a terse summary of the document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| securityLabel | S Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.securityLabelShort description Document security-tags DefinitionA 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. Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| content | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contentShort description Document referenced DefinitionThe document and format referenced. There may be multiple content element repetitions, each with a different format. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attachment | Σ C | 1..1 | Attachment | There are no (further) constraints on this element Element idDocumentReference.content.attachmentShort description Where to access the document DefinitionThe document or URL of the document along with critical metadata to prove content has integrity. 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". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.attachment.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contentType | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.content.attachment.contentTypeShort description Mime type of the content, with charset etc. DefinitionIdentifies 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. Processors of the data need to be able to know how to interpret the data. Note that FHIR strings SHALL NOT exceed 1MB in size The mime type of an attachment. Any valid mime type is allowed. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General text/plain; charset=UTF-8, image/pngMappings
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| language | Σ | 0..1 | codeBinding | Element idDocumentReference.content.attachment.languageShort description Human language of the content DefinitionThe human language of the content. Within NHS Wales, the three character ISO 639-3 code should be used where possible e.g. "eng" for English, "cym" for Welsh. Users need to be able to choose between the languages in a set of attachments. ISO 639-3 is a subset of the BCP 47 standard. Note that FHIR strings SHALL NOT exceed 1MB in size A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General en-AUMappings
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| data | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.dataShort description Data inline, base64ed DefinitionThe actual data of the attachment - a sequence of bytes, base64 encoded. The data needs to able to be transmitted inline. The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| url | Σ | 0..1 | url | There are no (further) constraints on this element Element idDocumentReference.content.attachment.urlShort description Uri where the data can be found DefinitionA location where the data can be accessed. The data needs to be transmitted by reference. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/logo-small.pngMappings
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| size | Σ | 0..1 | unsignedInt | There are no (further) constraints on this element Element idDocumentReference.content.attachment.sizeShort description Number of bytes of content (if url provided) DefinitionThe number of bytes of data that make up this attachment (before base64 encoding, if that is done). Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| hash | Σ | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.hashShort description Hash of the data (sha-1, base64ed) DefinitionThe calculated hash of the data using SHA-1. Represented using base64. 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). 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| title | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.titleShort description Label to display in place of the data DefinitionA label or set of text to display in place of the data. 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. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General Official Corporate LogoMappings
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| creation | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idDocumentReference.content.attachment.creationShort description Date attachment was first created DefinitionThe date that the attachment was first created. This is often tracked as an integrity issue for use of the attachment. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| format | Σ | 0..1 | CodingBinding | Element idDocumentReference.content.formatShort description Format/content rules for the document DefinitionAn identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. This optional field is not part of the formal metadata standard for document submission in Wales. It should not be confused with mime type which is stored as content.attachment.contentType. Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. Document Format Codes. DocumentReferenceFormatCodeSet (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| context | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contextShort description Clinical context of document DefinitionThe clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.context.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| encounter | C | 0..* | Reference(EpisodeOfCare | DataStandardsWalesEncounter) | Element idDocumentReference.context.encounterShort description Context of the document content DefinitionDescribes the clinical encounter or type of care that the document content is associated with. 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. Reference(EpisodeOfCare | DataStandardsWalesEncounter) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| event | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.eventShort description Main clinical acts documented DefinitionThis 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. 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. This list of codes represents the main clinical acts being documented. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.context.periodShort description Time of service that is being documented DefinitionThe time period over which the service that is described by the document was provided. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| facilityType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.facilityTypeShort description Kind of facility where patient was seen DefinitionThe kind of facility where the patient was seen. 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. XDS Facility Type. FacilityTypeCodeValueSet (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| practiceSetting | S | 0..1 | CodeableConceptBinding | Element idDocumentReference.context.practiceSettingShort description Additional details about where the content was created (e.g. clinical specialty) DefinitionThis property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. 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. Additional details about where the content was created (e.g. clinical specialty). UKCorePracticeSettingCode (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourcePatientInfo | C | 0..0 | Reference(DataStandardsWalesPatient) | Element idDocumentReference.context.sourcePatientInfoShort description Patient demographics from source DefinitionThe Patient Information as known when the document was published. May be a reference to a version specific, or contained. 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. Reference(DataStandardsWalesPatient) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| related | C | 0..* | Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.context.relatedShort description Related identifiers or resources DefinitionRelated identifiers or resources associated with the DocumentReference. May be identifiers or resources that caused the DocumentReference or referenced Document to be created. Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| DataStandardsWalesDocumentReference (DocumentReference) | C | DocumentReference | There are no (further) constraints on this element Element idDocumentReferenceShort description A reference to a document DefinitionA 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. Usually, this is used for documents other than those defined by FHIR.
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| id | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.idShort description Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. | ||
| meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idDocumentReference.metaShort description Metadata about the resource DefinitionThe 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idDocumentReference.implicitRulesShort description A set of rules under which this content was created DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| language | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.languageShort description Language of the resource content DefinitionThe base language in which the resource is written. 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). A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| text | 0..1 | Narrative | There are no (further) constraints on this element Element idDocumentReference.textShort description Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contained | 0..* | Resource | There are no (further) constraints on this element Element idDocumentReference.containedShort description Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese 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. 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.
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| extension | C | 1..* | Extension | There are no (further) constraints on this element Element idDocumentReference.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| digitalStatus | C | 1..1 | Extension(code) | Element idDocumentReference.extension:digitalStatusShort description Document digital status Alternate namesextensions, user content DefinitionThe digital status of the document. Indicates whether the document was always digital or created from a paper original via scanning. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentDigitalStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourceSystem | S C | 0..1 | Extension(Reference(DataStandardsWalesDevice)) | Element idDocumentReference.extension:sourceSystemShort description The source system for the document details. Alternate namesextensions, user content DefinitionThe system from which the document details were sourced to create the document reference. 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. Extension(Reference(DataStandardsWalesDevice)) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-SourceSystem ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| versionR5 | S C | 0..1 | Extension | Element idDocumentReference.extension:versionR5Short description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.version ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attesterR5 | S C | 0..* | Extension(Complex) | Element idDocumentReference.extension:attesterR5Short description Attests to accuracy of the document. Alternate namesextensions, user content DefinitionA participant who has authenticated the accuracy of the document. (Backport from FHIR R5.) 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentReference.attester ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorStatus | S C | 0..1 | Extension(code) | Element idDocumentReference.extension:errorStatusShort description Document error status Alternate namesextensions, user content DefinitionAn extension to carry a descriptive code for the document error status e.g. potential-misfile. The error status can be used by systems to affect document handling and presentation e.g. watermarking. 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. https://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorStatus ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| errorAction | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:errorActionShort description Document error action metadata. Alternate namesextensions, user content DefinitionThis extension provides outline data for an action performed as part of a document error workflow e.g. document misfile proposed. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentErrorAction ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| documentAttribute | C | 0..* | Extension(Complex) | Element idDocumentReference.extension:documentAttributeShort description Additional metadata for the document Alternate namesextensions, user content DefinitionAdditional metadata as applicable to the document type. This element should be used with care to avoid a proliferation of undefined metadata. 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. Extension(Complex) Extension URLhttps://fhir.nhs.wales/StructureDefinition/Extension-DataStandardsWales-DocumentAttribute ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.modifierExtensionShort description Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay 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). 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| masterIdentifier | Σ | 0..0 | Identifier | There are no (further) constraints on this element Element idDocumentReference.masterIdentifierShort description Master Version Specific Identifier DefinitionDocument 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. 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.). CDA Document Id extension and root. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| identifier | S Σ | 0..* | Identifier | Element idDocumentReference.identifierShort description Other identifiers for the document DefinitionOther identifiers associated with the document, including version independent identifiers. Unordered, Open, by Slices provided for the different types of national identifiers issued by the Welsh Care Records Service. ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsDocumentId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsDocumentIdShort description The WCRS DocumentId. DefinitionThe version-specific DocumentId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsDocumentId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-document-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsDocumentId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| wcrsSupersessionSetId | Σ | 0..1 | Identifier | Element idDocumentReference.identifier:wcrsSupersessionSetIdShort description The WCRS DocumentSupersessionSetId. DefinitionThe version-independent DocumentSupersessionSetId issued by the Welsh Care Records Service. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.useShort description usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known . The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.typeShort description Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. 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. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| system | Σ | 0..1 | uriFixed Value | Element idDocumentReference.identifier:wcrsSupersessionSetId.systemShort description The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. 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. Identifier.system is always case sensitive. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
https://fhir.nhs.wales/Id/wcrs-supersession-set-identifierExamples General http://www.acme.com/identifiers/patientMappings
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| value | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.valueShort description The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General 123456Mappings
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.periodShort description Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| assigner | Σ C | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idDocumentReference.identifier:wcrsSupersessionSetId.assignerShort description Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.statusShort description current | superseded | entered-in-error DefinitionThe status of this document reference. 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. The status of the document reference. DocumentReferenceStatus (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| docStatus | S Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.docStatusShort description preliminary | final | amended | entered-in-error DefinitionThe status of the underlying document. The document that is pointed to might be in various lifecycle states. Status of the underlying document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| type | S Σ | 1..1 | CodeableConceptBinding | Element idDocumentReference.typeShort description Kind of document DefinitionSpecifies 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. 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. Precise type of clinical document. DataStandardsWalesDocumentType (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| category | S Σ | 1..* | CodeableConceptBinding | Element idDocumentReference.categoryShort description Categorization of document Alternate namesclaxs DefinitionA 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. 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. High-level kind of a clinical document at a macro level. DataStandardsWalesDocumentCategory (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| subject | S Σ C | 0..1 | Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) | Element idDocumentReference.subjectShort description Who/what is the subject of the document DefinitionWho 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). 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. Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| date | S Σ | 0..1 | instant | There are no (further) constraints on this element Element idDocumentReference.dateShort description When this document reference was created Alternate namesindexed DefinitionWhen the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| author | S Σ C | 0..* | Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) | Element idDocumentReference.authorShort description Who and/or what authored the document DefinitionIdentifies who is responsible for adding the information to the document. Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| authenticator | C | 0..0 | Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.authenticatorShort description Who/what authenticated the document DefinitionWhich person or organization authenticates that this document is valid. 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. Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| custodian | S C | 0..1 | Reference(DataStandardsWalesOrganization) | Element idDocumentReference.custodianShort description Organization which maintains the document DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the document. 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. Reference(DataStandardsWalesOrganization) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| relatesTo | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.relatesToShort description Relationships to other documents DefinitionRelationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.relatesTo.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.relatesTo.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| code | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.relatesTo.codeShort description replaces | transforms | signs | appends DefinitionThe type of relationship that this document has with anther document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| target | Σ C | 1..1 | Reference(DataStandardsWalesDocumentReference) | Element idDocumentReference.relatesTo.targetShort description Target of the relationship DefinitionThe target document of this relationship. 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. Reference(DataStandardsWalesDocumentReference) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| description | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.descriptionShort description Human-readable description DefinitionHuman-readable description of the source document. Helps humans to assess whether the document is of interest. What the document is about, a terse summary of the document. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| securityLabel | S Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element idDocumentReference.securityLabelShort description Document security-tags DefinitionA 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. Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. 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. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| content | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contentShort description Document referenced DefinitionThe document and format referenced. There may be multiple content element repetitions, each with a different format. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| attachment | Σ C | 1..1 | Attachment | There are no (further) constraints on this element Element idDocumentReference.content.attachmentShort description Where to access the document DefinitionThe document or URL of the document along with critical metadata to prove content has integrity. 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". The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.content.attachment.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| contentType | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idDocumentReference.content.attachment.contentTypeShort description Mime type of the content, with charset etc. DefinitionIdentifies 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. Processors of the data need to be able to know how to interpret the data. Note that FHIR strings SHALL NOT exceed 1MB in size The mime type of an attachment. Any valid mime type is allowed. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General text/plain; charset=UTF-8, image/pngMappings
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| language | Σ | 0..1 | codeBinding | Element idDocumentReference.content.attachment.languageShort description Human language of the content DefinitionThe human language of the content. Within NHS Wales, the three character ISO 639-3 code should be used where possible e.g. "eng" for English, "cym" for Welsh. Users need to be able to choose between the languages in a set of attachments. ISO 639-3 is a subset of the BCP 47 standard. Note that FHIR strings SHALL NOT exceed 1MB in size A human language.
The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General en-AUMappings
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| data | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.dataShort description Data inline, base64ed DefinitionThe actual data of the attachment - a sequence of bytes, base64 encoded. The data needs to able to be transmitted inline. The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| url | Σ | 0..1 | url | There are no (further) constraints on this element Element idDocumentReference.content.attachment.urlShort description Uri where the data can be found DefinitionA location where the data can be accessed. The data needs to be transmitted by reference. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General http://www.acme.com/logo-small.pngMappings
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| size | Σ | 0..1 | unsignedInt | There are no (further) constraints on this element Element idDocumentReference.content.attachment.sizeShort description Number of bytes of content (if url provided) DefinitionThe number of bytes of data that make up this attachment (before base64 encoding, if that is done). Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| hash | Σ | 0..1 | base64Binary | There are no (further) constraints on this element Element idDocumentReference.content.attachment.hashShort description Hash of the data (sha-1, base64ed) DefinitionThe calculated hash of the data using SHA-1. Represented using base64. 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). 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| title | Σ | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.content.attachment.titleShort description Label to display in place of the data DefinitionA label or set of text to display in place of the data. 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. Note that FHIR strings SHALL NOT exceed 1MB in size The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
General Official Corporate LogoMappings
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| creation | Σ | 0..1 | dateTime | There are no (further) constraints on this element Element idDocumentReference.content.attachment.creationShort description Date attachment was first created DefinitionThe date that the attachment was first created. This is often tracked as an integrity issue for use of the attachment. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| format | Σ | 0..1 | CodingBinding | Element idDocumentReference.content.formatShort description Format/content rules for the document DefinitionAn identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. This optional field is not part of the formal metadata standard for document submission in Wales. It should not be confused with mime type which is stored as content.attachment.contentType. Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. Document Format Codes. DocumentReferenceFormatCodeSet (preferred) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| context | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element idDocumentReference.contextShort description Clinical context of document DefinitionThe clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idDocumentReference.context.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay 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. 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. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idDocumentReference.context.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay 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). 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. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| encounter | C | 0..* | Reference(EpisodeOfCare | DataStandardsWalesEncounter) | Element idDocumentReference.context.encounterShort description Context of the document content DefinitionDescribes the clinical encounter or type of care that the document content is associated with. 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. Reference(EpisodeOfCare | DataStandardsWalesEncounter) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| event | 0..* | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.eventShort description Main clinical acts documented DefinitionThis 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. 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. This list of codes represents the main clinical acts being documented. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| period | Σ C | 0..1 | Period | There are no (further) constraints on this element Element idDocumentReference.context.periodShort description Time of service that is being documented DefinitionThe time period over which the service that is described by the document was provided. 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. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| facilityType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idDocumentReference.context.facilityTypeShort description Kind of facility where patient was seen DefinitionThe kind of facility where the patient was seen. 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. XDS Facility Type. FacilityTypeCodeValueSet (example) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| practiceSetting | S | 0..1 | CodeableConceptBinding | Element idDocumentReference.context.practiceSettingShort description Additional details about where the content was created (e.g. clinical specialty) DefinitionThis property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. 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. Additional details about where the content was created (e.g. clinical specialty). UKCorePracticeSettingCode (required) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| sourcePatientInfo | C | 0..0 | Reference(DataStandardsWalesPatient) | Element idDocumentReference.context.sourcePatientInfoShort description Patient demographics from source DefinitionThe Patient Information as known when the document was published. May be a reference to a version specific, or contained. 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. Reference(DataStandardsWalesPatient) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| related | C | 0..* | Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) | Element idDocumentReference.context.relatedShort description Related identifiers or resources DefinitionRelated identifiers or resources associated with the DocumentReference. May be identifiers or resources that caused the DocumentReference or referenced Document to be created. Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole) ConditionsThe cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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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:
- A status
- A digital status
- A type
- One or more categories
- One or more attachments as either a base 64 binary or a URL.
Each DocumentReference must support:
- One or more identifiers
- A document status
- An error status (applicable if document is entered in error)
- A subject
- A date
- One or more authors
- One or more attesters
- A custodian
- One or more security labels
- A practice setting
- A source system
- 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
- UNK
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:
- Data Standards Wales extensions
- Extension-DataStandardsWales-DocumentDigitalStatus supports the capture of a mandatory indication of whether the document was born digital or scanned.
- Extension-DataStandardsWales-SourceSystem supports the identification of the system which supplied the document details.
- Extension-DataStandardsWales-DocumentVersion supports the capture of a document version as defined in FHIR R5.
- Extension-DataStandardsWales-DocumentAttester supports the capture of attester details as defined in FHIR R5 via a complex extension.
- Extension-DataStandardsWales-DocumentErrorStatus supports the exchange of information about the validity of the document.
- Extension-DataStandardsWales-DocumentErrorAction supports the capture of the error workflow actions that led to the current error status.
- Extension-DataStandardsWales-DocumentAttribute supports the capture of additional document metadata via a complex extension.