Australian Digital Health Agency FHIR Implementation Guide 1.1.0

This page is part of the Australian Digital Health Agency FHIR Implementation Guide 1.1.0. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available previous versions.

StructureDefinition: ADHA Core DocumentReference [Active]

The purpose of this profile is to provide a core representation of a document reference for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile supports describing a generic document that is made available to a system and is used for documents that are not authored and assembled in FHIR e.g. documents whose form is an attachment.

This profile identifies the additional constraints, extensions, and value sets that build on and extend DocumentReference that are supported.

Where a more specific DocumentReference profile is applicable, e.g. advance care plan , an implementation SHALL ensure the resource conforms to that specific profile.

This profile is designed to set a core DocumentReference standard for:

  • Query for a generic document reference for a patient
  • Record or update a generic document reference belonging to a patient

Profile specific guidance

None.

Boundaries and relationships

This profile is referenced by ADHA Core Procedure.

Formal Views of Profile Content

The official URL for this profile is: 

http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-documentreference-core-1

The purpose of this profile is to provide a core representation of a document reference for the electronic exchange of health information between individuals, healthcare providers, and the My Health Record system infrastructure in Australia. This profile supports describing a document that is made available to a system and is used for documents that are not authored and assembled in FHIR e.g. documents whose form is an attachment.

This profile builds on DocumentReference.

This profile was published on 2023-08-07 09:41:43+1000 as a active by Australian Digital Health Agency.

Description of Profiles, Differentials, Snapshots, and how the XML and JSON presentations work.

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C0..*DocumentReferenceA reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... masterIdentifier S0..1IdentifierMaster Version Specific Identifier
... identifier S1..*IdentifierOther identifiers for the document
... status S1..1codecurrent | superseded | entered-in-error
... docStatus S0..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of document (LOINC if possible)
... category S1..*CodeableConceptCategorization of document
... subject SC1..1Reference(ADHA Core Patient)Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date S1..1instantWhen this document reference was created
... author SC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S0..1Reference(ADHA Core PractitionerRole | ADHA Core Organization)Who/what authenticated the document
... custodian SC0..1Reference(ADHA Core Organization)Organization which maintains the document
... description S0..1stringHuman-readable description
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..*Reference(ADHA Core Encounter)Context of the document content

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C0..*DocumentReferenceA reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier SΣ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ1..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC1..1Reference(ADHA Core Patient)Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ1..1instantWhen this document reference was created
... author SΣC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S0..1Reference(ADHA Core PractitionerRole | ADHA Core Organization)Who/what authenticated the document
... custodian SC0..1Reference(ADHA Core Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(ADHA Core Encounter)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Differential View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C0..*DocumentReferenceA reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... masterIdentifier S0..1IdentifierMaster Version Specific Identifier
... identifier S1..*IdentifierOther identifiers for the document
... status S1..1codecurrent | superseded | entered-in-error
... docStatus S0..1codepreliminary | final | amended | entered-in-error
... type S1..1CodeableConceptKind of document (LOINC if possible)
... category S1..*CodeableConceptCategorization of document
... subject SC1..1Reference(ADHA Core Patient)Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date S1..1instantWhen this document reference was created
... author SC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S0..1Reference(ADHA Core PractitionerRole | ADHA Core Organization)Who/what authenticated the document
... custodian SC0..1Reference(ADHA Core Organization)Organization which maintains the document
... description S0..1stringHuman-readable description
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..*Reference(ADHA Core Encounter)Context of the document content

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference C0..*DocumentReferenceA reference to a document
inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier SΣ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ1..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣC1..1Reference(ADHA Core Patient)Who/what is the subject of the document
inv-dh-docref-01: At least reference or a valid identifier shall be present
... date SΣ1..1instantWhen this document reference was created
... author SΣC1..*Reference(ADHA Authoring PractitionerRole | ADHA Core Organization | ADHA System Device | ADHA Core Patient | ADHA Authoring RelatedPerson)Who and/or what authored the document
inv-dh-docref-02: At least reference or a valid identifier shall be present
... authenticator S0..1Reference(ADHA Core PractitionerRole | ADHA Core Organization)Who/what authenticated the document
... custodian SC0..1Reference(ADHA Core Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(ADHA Core Encounter)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Downloads: StructureDefinition: (XML, JSON), Schema: XML Schematron

 

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Search Parameters

None defined.