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

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Resource Profile: Research Document Reference

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

Usage:

• Examples for this Resource Profile: DocumentReference/research-document-reference-example-1

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
subject		1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
custodian		1..1	Reference(Organization)	Organization which maintains the document
content
attachment		1..1	DRSAttachment	Content in a format defined elsewhere
context		1..1	BackboneElement	Clinical context of document
related		0..*	Reference(Task)	Related identifiers or resources
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	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
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
subject	Σ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
custodian		1..1	Reference(Organization)	Organization which maintains the document
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	C	1..1	DRSAttachment	Content in a format defined elsewhere
context	Σ	1..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
related		0..*	Reference(Task)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
must-be-drs-uri	error	DocumentReference.content.attachment	attachment.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://.*')

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	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	Σ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	Σ	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		1..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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	C	1..1	DRSAttachment	Content in a format defined elsewhere
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	1..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	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(Task)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
must-be-drs-uri	error	DocumentReference.content.attachment	attachment.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:

• DRS Attachment (https://nih-ncpi.github.io/ncpi-fhir-ig/StructureDefinition/ncpi-drs-attachment)

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
subject		1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
custodian		1..1	Reference(Organization)	Organization which maintains the document
content
attachment		1..1	DRSAttachment	Content in a format defined elsewhere
context		1..1	BackboneElement	Clinical context of document
related		0..*	Reference(Task)	Related identifiers or resources
Documentation for this format

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	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
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
subject	Σ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
custodian		1..1	Reference(Organization)	Organization which maintains the document
content	Σ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	C	1..1	DRSAttachment	Content in a format defined elsewhere
context	Σ	1..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
related		0..*	Reference(Task)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
must-be-drs-uri	error	DocumentReference.content.attachment	attachment.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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	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	Σ	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	Σ	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		1..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
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
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	Σ	1..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	C	1..1	DRSAttachment	Content in a format defined elsewhere
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	1..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	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(Task)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
must-be-drs-uri	error	DocumentReference.content.attachment	attachment.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:

• DRS Attachment (https://nih-ncpi.github.io/ncpi-fhir-ig/StructureDefinition/ncpi-drs-attachment)

Other representations of profile: CSV, Excel, Schematron