NCPI FHIR Implementation Guide
0.2.0 - ci-build

NCPI FHIR Implementation Guide - Local Development build (v0.2.0). See the Directory of published versions

Resource Profile: Research Document Reference

Official URL: https://nih-ncpi.github.io/ncpi-fhir-ig/StructureDefinition/ncpi-research-document-reference Version: 0.2.0
Draft as of 2022-10-31 Computable Name: ResearchDocumentReference

A FHIR Document Reference created by an analysis task. Context.related = Task

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... subject 1..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... custodian 1..1Reference(Organization)Organization which maintains the document
... content
.... attachment 1..1DRSAttachmentContent in a format defined elsewhere
.... related 0..*Reference(Task)Related identifiers or resources

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... custodian 1..1Reference(Organization)Organization which maintains the document
... content Σ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment C1..1DRSAttachmentContent in a format defined elsewhere
... context Σ1..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... related 0..*Reference(Task)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus

Constraints

IdGradePath(s)DetailsRequirements
att-1errorDocumentReference.content.attachmentIf the Attachment has data, it SHALL have a contentType
: data.empty() or contentType.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
must-be-drs-urierrorDocumentReference.content.attachmentattachment.url must start with ^drs://. A drs:// hostname-based URI, as defined in the DRS documentation, that tells clients how to access this object. The intent of this field is to make DRS objects self-contained, and therefore easier for clients to store and pass around. For example, if you arrive at this DRS JSON by resolving a compact identifier-based DRS URI, the `self_uri` presents you with a hostname and properly encoded DRS ID for use in subsequent `access` endpoint calls.
: $this.url.matches('^drs://.*')
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... 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
... 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 Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type Σ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ1..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 1..1Reference(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 Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..*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 C1..1DRSAttachmentContent in a format defined elsewhere
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ1..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 0..*Reference(Encounter | EpisodeOfCare)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(Task)Related identifiers or resources

doco Documentation for this format

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

Constraints

IdGradePath(s)DetailsRequirements
att-1errorDocumentReference.content.attachmentIf the Attachment has data, it SHALL have a contentType
: data.empty() or contentType.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
must-be-drs-urierrorDocumentReference.content.attachmentattachment.url must start with ^drs://. A drs:// hostname-based URI, as defined in the DRS documentation, that tells clients how to access this object. The intent of this field is to make DRS objects self-contained, and therefore easier for clients to store and pass around. For example, if you arrive at this DRS JSON by resolving a compact identifier-based DRS URI, the `self_uri` presents you with a hostname and properly encoded DRS ID for use in subsequent `access` endpoint calls.
: $this.url.matches('^drs://.*')

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... subject 1..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... custodian 1..1Reference(Organization)Organization which maintains the document
... content
.... attachment 1..1DRSAttachmentContent in a format defined elsewhere
.... related 0..*Reference(Task)Related identifiers or resources

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... custodian 1..1Reference(Organization)Organization which maintains the document
... content Σ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment C1..1DRSAttachmentContent in a format defined elsewhere
... context Σ1..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... related 0..*Reference(Task)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus

Constraints

IdGradePath(s)DetailsRequirements
att-1errorDocumentReference.content.attachmentIf the Attachment has data, it SHALL have a contentType
: data.empty() or contentType.exists()
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf 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-4errorDocumentReferenceIf 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-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
must-be-drs-urierrorDocumentReference.content.attachmentattachment.url must start with ^drs://. A drs:// hostname-based URI, as defined in the DRS documentation, that tells clients how to access this object. The intent of this field is to make DRS objects self-contained, and therefore easier for clients to store and pass around. For example, if you arrive at this DRS JSON by resolving a compact identifier-based DRS URI, the `self_uri` presents you with a hostname and properly encoded DRS ID for use in subsequent `access` endpoint calls.
: $this.url.matches('^drs://.*')

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... 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
... 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 Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!Σ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type Σ0..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category Σ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject Σ1..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... date Σ0..1instantWhen this document reference was created
... author Σ0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 1..1Reference(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 Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..*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 C1..1DRSAttachmentContent in a format defined elsewhere
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ1..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 0..*Reference(Encounter | EpisodeOfCare)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(Task)Related identifiers or resources

doco Documentation for this format

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

Constraints

IdGradePath(s)DetailsRequirements
att-1errorDocumentReference.content.attachmentIf the Attachment has data, it SHALL have a contentType
: data.empty() or contentType.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
must-be-drs-urierrorDocumentReference.content.attachmentattachment.url must start with ^drs://. A drs:// hostname-based URI, as defined in the DRS documentation, that tells clients how to access this object. The intent of this field is to make DRS objects self-contained, and therefore easier for clients to store and pass around. For example, if you arrive at this DRS JSON by resolving a compact identifier-based DRS URI, the `self_uri` presents you with a hostname and properly encoded DRS ID for use in subsequent `access` endpoint calls.
: $this.url.matches('^drs://.*')

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron