IE (Ireland) Core Implementation Guide
0.3.0 - draft
IE (Ireland) Core Implementation Guide
0.3.0 - draft
IE (Ireland) Core Implementation Guide - Local Development build (v0.3.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://hl7-ie.github.io/ie-core/fhir/ie/core/StructureDefinition/ie-core-documentreference | Version: 0.3.0 | |||
| Draft as of 2026-09-28 | Computable Name: IECoreDocumentReference | |||
The IE Core DocumentReference profile sets minimum expectations for the DocumentReference resource to record, search, and fetch documents associated with a patient, based on Irish requirements.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:   |
|---|---|---|---|---|
  DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |
  implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1 |
 identifier |
SΣ | 0..* | Identifier | Other identifiers for the document |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) |
| category |
SΣ | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) |
 subject |
SΣ | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document |
| date |
SΣ | 0..1 | instant | When this document reference was created |
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 |
 attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document |
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 |
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content |
| period |
SΣ | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | DocumentReference.implicitRules, DocumentReference.modifierExtension, DocumentReference.identifier, DocumentReference.status, DocumentReference.type, DocumentReference.category, DocumentReference.subject, DocumentReference.date, DocumentReference.author, DocumentReference.content, DocumentReference.content.modifierExtension, DocumentReference.content.attachment, DocumentReference.context, DocumentReference.context.modifierExtension, DocumentReference.context.encounter, DocumentReference.context.period | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | DocumentReference.modifierExtension, DocumentReference.content.modifierExtension, DocumentReference.context.modifierExtension | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |
 identifier |
S | 0..* | Identifier | Other identifiers for the document |
| status |
S | 1..1 | code | current | superseded | entered-in-error |
| type |
S | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) |
| category |
S | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) |
| subject |
S | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document |
| date |
S | 0..1 | instant | When this document reference was created |
| author |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| content |
S | 1..* | BackboneElement | Document referenced |
| attachment |
S | 1..1 | Attachment | Where to access the document |
| context |
S | 0..1 | BackboneElement | Clinical context of document |
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content |
| period |
S | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1 | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) | ||||
| category |
SΣ | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) | ||||
| subject |
SΣ | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| attachment |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | ||||
| event |
0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v7.4 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | DocumentReference.meta, DocumentReference.implicitRules, DocumentReference.language, DocumentReference.text, DocumentReference.extension, DocumentReference.modifierExtension, DocumentReference.masterIdentifier, DocumentReference.identifier, DocumentReference.status, DocumentReference.docStatus, DocumentReference.type, DocumentReference.category, DocumentReference.subject, DocumentReference.date, DocumentReference.author, DocumentReference.authenticator, DocumentReference.custodian, DocumentReference.relatesTo, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.relatesTo.code, DocumentReference.relatesTo.target, DocumentReference.description, DocumentReference.securityLabel, DocumentReference.content, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.content.attachment, DocumentReference.content.format, DocumentReference.context, DocumentReference.context.extension, DocumentReference.context.modifierExtension, DocumentReference.context.encounter, DocumentReference.context.event, DocumentReference.context.period, DocumentReference.context.facilityType, DocumentReference.context.practiceSetting, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | DocumentReference.extension, DocumentReference.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.context.extension, DocumentReference.context.modifierExtension | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DocumentReference
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created |
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1 |
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document |
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) |
| category |
SΣ | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) |
| subject |
SΣ | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document |
| date |
SΣ | 0..1 | instant | When this document reference was created |
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| content |
SΣ | 1..* | BackboneElement | Document referenced |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 |
| attachment |
SΣ | 1..1 | Attachment | Where to access the document |
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document |
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 |
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content |
| period |
SΣ | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | DocumentReference.implicitRules, DocumentReference.modifierExtension, DocumentReference.identifier, DocumentReference.status, DocumentReference.type, DocumentReference.category, DocumentReference.subject, DocumentReference.date, DocumentReference.author, DocumentReference.content, DocumentReference.content.modifierExtension, DocumentReference.content.attachment, DocumentReference.context, DocumentReference.context.modifierExtension, DocumentReference.context.encounter, DocumentReference.context.period | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | DocumentReference.modifierExtension, DocumentReference.content.modifierExtension, DocumentReference.context.modifierExtension | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |
| identifier |
S | 0..* | Identifier | Other identifiers for the document |
| status |
S | 1..1 | code | current | superseded | entered-in-error |
| type |
S | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) |
| category |
S | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) |
| subject |
S | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document |
| date |
S | 0..1 | instant | When this document reference was created |
| author |
S | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| content |
S | 1..* | BackboneElement | Document referenced |
| attachment |
S | 1..1 | Attachment | Where to access the document |
| context |
S | 0..1 | BackboneElement | Clinical context of document |
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content |
| period |
S | 0..1 | Period | Time of service that is being documented |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference(4.0.1) | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| language |
0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?! | 0..* | Extension | Extensions that cannot be ignored Constraints: ext-1 | ||||
| masterIdentifier |
Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
| identifier |
SΣ | 0..* | Identifier | Other identifiers for the document | ||||
| status |
?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
| docStatus |
Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
| type |
SΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: IECoreDocumentReferenceType (0.3.0) (extensible) | ||||
| category |
SΣ | 0..* | CodeableConcept | Categorization of document Binding: IECoreDocumentReferenceCategory (0.3.0) (extensible) | ||||
| subject |
SΣ | 0..1 | Reference(IE Core Patient(0.3.0)) | Who/what is the subject of the document | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
Σ | 0..* | BackboneElement | Relationships to other documents | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| content |
SΣ | 1..* | BackboneElement | Document referenced | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| attachment |
SΣ | 1..1 | Attachment | Where to access the document | ||||
| format |
Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
| context |
SΣ | 0..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Constraints: ext-1 | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized Constraints: ext-1 | ||||
| encounter |
S | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | ||||
| event |
0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| related |
0..* | Reference(Resource) | Related identifiers or resources | |||||
| Documentation for this format | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | extensible | IE Core DocumentReference Type | 📍0.3.0 | This IG |
| DocumentReference.category | Base | extensible | IE Core DocumentReference Category | 📍0.3.0 | This IG |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📍3.0.0 | THO v7.4 |
| DocumentReference.context.facilityType | Base | example | Facility Type Code Value Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.practiceSetting | Base | example | Practice Setting Code Value Set | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
|
| dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated |
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
|
| dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label |
contained.meta.security.empty()
|
| dom-6 | best practice | DocumentReference | A resource should have narrative for robust management |
text.`div`.exists()
|
| ele-1 | error | DocumentReference.meta, DocumentReference.implicitRules, DocumentReference.language, DocumentReference.text, DocumentReference.extension, DocumentReference.modifierExtension, DocumentReference.masterIdentifier, DocumentReference.identifier, DocumentReference.status, DocumentReference.docStatus, DocumentReference.type, DocumentReference.category, DocumentReference.subject, DocumentReference.date, DocumentReference.author, DocumentReference.authenticator, DocumentReference.custodian, DocumentReference.relatesTo, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.relatesTo.code, DocumentReference.relatesTo.target, DocumentReference.description, DocumentReference.securityLabel, DocumentReference.content, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.content.attachment, DocumentReference.content.format, DocumentReference.context, DocumentReference.context.extension, DocumentReference.context.modifierExtension, DocumentReference.context.encounter, DocumentReference.context.event, DocumentReference.context.period, DocumentReference.context.facilityType, DocumentReference.context.practiceSetting, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related | All FHIR elements must have a @value or children |
hasValue() or (children().count() > id.count())
|
| ext-1 | error | DocumentReference.extension, DocumentReference.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.context.extension, DocumentReference.context.modifierExtension | Must have either extensions or value[x], not both |
extension.exists() != value.exists()
|
This structure is derived from DocumentReference
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