DataStandardsWales-DocumentReference

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

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

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

Formal Views of Profile Content

idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
id0..1string
extensionC0..0Extension
value0..1System.String
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueStringstring
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodeableConceptCodeableConcept
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueDateTimedateTime
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueReferenceReference(DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
url1..1uriFixed Value
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ1..1CodeableConceptBinding
categoryS Σ1..*CodeableConceptBinding
subjectS Σ C0..1Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner)
dateS Σ0..1instant
authorS Σ C0..*Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson)
authenticatorC0..0Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
custodianS C0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ C1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
id0..1string
extensionC0..*Extension
contentTypeΣ0..1codeBinding
languageΣ0..1codeBinding
data0..1base64Binary
urlΣ0..1url
sizeΣ0..1unsignedInt
hashΣ0..1base64Binary
titleΣ0..1string
creationΣ0..1dateTime
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounterC0..*Reference(EpisodeOfCare | DataStandardsWalesEncounter)
event0..*CodeableConcept
periodΣ C0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfoC0..0Reference(DataStandardsWalesPatient)
relatedC0..*Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
id0..1string
extensionC0..0Extension
value0..1System.String
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueStringstring
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodeableConceptCodeableConcept
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueDateTimedateTime
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueReferenceReference(DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
url1..1uriFixed Value
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ1..1CodeableConceptBinding
categoryS Σ1..*CodeableConceptBinding
subjectS Σ C0..1Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner)
dateS Σ0..1instant
authorS Σ C0..*Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson)
authenticatorC0..0Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
custodianS C0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ C1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
id0..1string
extensionC0..*Extension
contentTypeΣ0..1codeBinding
languageΣ0..1codeBinding
data0..1base64Binary
urlΣ0..1url
sizeΣ0..1unsignedInt
hashΣ0..1base64Binary
titleΣ0..1string
creationΣ0..1dateTime
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounterC0..*Reference(EpisodeOfCare | DataStandardsWalesEncounter)
event0..*CodeableConcept
periodΣ C0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfoC0..0Reference(DataStandardsWalesPatient)
relatedC0..*Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
idΣ0..1string
metaΣ0..1Meta
implicitRulesΣ ?!0..1uri
language0..1codeBinding
text0..1Narrative
contained0..*Resource
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
id0..1string
extensionC0..0Extension
value0..1System.String
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueStringstring
id0..1string
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueCodeableConceptCodeableConcept
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueDateTimedateTime
id0..1string
extensionC0..0Extension
url1..1uriFixed Value
valueReferenceReference(DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
url1..1uriFixed Value
modifierExtension?! C0..*Extension
masterIdentifierΣ0..0Identifier
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
id0..1string
extensionC0..*Extension
useΣ ?!0..1codeBinding
typeΣ0..1CodeableConceptBinding
systemΣ0..1uriFixed Value
valueΣ0..1string
periodΣ C0..1Period
assignerΣ C0..1Reference(Organization)
statusΣ ?!1..1codeBinding
docStatusS Σ0..1codeBinding
typeS Σ1..1CodeableConceptBinding
categoryS Σ1..*CodeableConceptBinding
subjectS Σ C0..1Reference(Group | DataStandardsWalesDevice | DataStandardsWalesPatient | DataStandardsWalesPractitioner)
dateS Σ0..1instant
authorS Σ C0..*Reference(DataStandardsWalesDevice | DataStandardsWalesOrganization | DataStandardsWalesPatient | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole | DataStandardsWalesRelatedPerson)
authenticatorC0..0Reference(DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)
custodianS C0..1Reference(DataStandardsWalesOrganization)
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
codeΣ1..1codeBinding
targetΣ C1..1Reference(DataStandardsWalesDocumentReference)
descriptionΣ0..1string
securityLabelS Σ0..*CodeableConceptBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
id0..1string
extensionC0..*Extension
contentTypeΣ0..1codeBinding
languageΣ0..1codeBinding
data0..1base64Binary
urlΣ0..1url
sizeΣ0..1unsignedInt
hashΣ0..1base64Binary
titleΣ0..1string
creationΣ0..1dateTime
formatΣ0..1CodingBinding
id0..1string
extensionC0..*Extension
modifierExtensionΣ ?! C0..*Extension
encounterC0..*Reference(EpisodeOfCare | DataStandardsWalesEncounter)
event0..*CodeableConcept
periodΣ C0..1Period
facilityType0..1CodeableConcept
practiceSettingS0..1CodeableConceptBinding
sourcePatientInfoC0..0Reference(DataStandardsWalesPatient)
relatedC0..*Reference(Resource | DataStandardsWalesLocation | DataStandardsWalesOrganization | DataStandardsWalesPractitioner | DataStandardsWalesPractitionerRole)

Mandatory and Must Support Data Elements

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

Each DocumentReference must have:

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

Each DocumentReference must support:

  1. One or more identifiers
  2. A document status
  3. A subject
  4. A date
  5. One or more authors
  6. One or more attesters
  7. A custodian
  8. One or more security labels
  9. A practice setting
  10. A source system, identified in the meta.source element
  11. 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

  • Backport extensions

    • The following extensions are based on elements in the HL7 R5 DocumentReference resource definition. See Deployment for more information on dependencies.
      • ExtensionDocumentReference_Attester supports the identification of the person or entity that attested to the accuracy of the document. It is based on DocumentReference.attester in R5.
      • ExtensionDocumentReference_Version supports the capture of an explicitly assigned identifer of a variation of the content in the DocumentReference. It is based on DocumentReference.version in R5.