| Australian Digital Health Agency FHIR Implementation Guide 1.0.0

Australian Digital Health Agency FHIR Implementation Guide. This is the current published version. It is based on FHIR® version 4.0.1. See the Directory of published versions for a list of available 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 2023-04-14 04:02:01+0000 as a active by Australian Digital Health Agency.

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

- Differential Table
- Snapshot Table
- All

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference | C | 0..* | DocumentReference | A reference to a document inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
masterIdentifier | S | 0..1 | Identifier | Master Version Specific Identifier
identifier | S | 1..* | Identifier | Other identifiers for the document
status | S | 1..1 | code | current | superseded | entered-in-error
docStatus | S | 0..1 | code | preliminary | final | amended | entered-in-error
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible)
category | S | 1..* | CodeableConcept | Categorization of document
subject | S C | 1..1 | Reference(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 | S | 1..1 | instant | When this document reference was created
author | S C | 1..* | 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 | S | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Organization) | Who/what authenticated the document
custodian | S C | 0..1 | Reference(ADHA Core Organization) | Organization which maintains the document
description | S | 0..1 | string | Human-readable description
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(ADHA Core Encounter) | Context of the document content
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference | C | 0..* | DocumentReference | A reference to a document inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
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 | S Σ | 0..1 | Identifier | Master Version Specific Identifier
identifier | S Σ | 1..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus | S Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ C | 1..1 | Reference(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 | S Σ | 1..1 | instant | When this document reference was created
author | S Σ C | 1..* | 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 | S | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Organization) | Who/what authenticated the document
custodian | S C | 0..1 | Reference(ADHA Core 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 | S 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 | S 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 | S Σ | 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 | S Σ | 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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..* | Reference(ADHA Core Encounter) | 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(Resource) | Related identifiers or resources
Documentation for this format

Differential View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference | C | 0..* | DocumentReference | A reference to a document inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
masterIdentifier | S | 0..1 | Identifier | Master Version Specific Identifier
identifier | S | 1..* | Identifier | Other identifiers for the document
status | S | 1..1 | code | current | superseded | entered-in-error
docStatus | S | 0..1 | code | preliminary | final | amended | entered-in-error
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible)
category | S | 1..* | CodeableConcept | Categorization of document
subject | S C | 1..1 | Reference(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 | S | 1..1 | instant | When this document reference was created
author | S C | 1..* | 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 | S | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Organization) | Who/what authenticated the document
custodian | S C | 0..1 | Reference(ADHA Core Organization) | Organization which maintains the document
description | S | 0..1 | string | Human-readable description
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(ADHA Core Encounter) | Context of the document content
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference | C | 0..* | DocumentReference | A reference to a document inv-dh-docref-03: If present, a custodian shall at least have a reference or a valid identifier
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 | S Σ | 0..1 | Identifier | Master Version Specific Identifier
identifier | S Σ | 1..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus | S Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category | S Σ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | S Σ C | 1..1 | Reference(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 | S Σ | 1..1 | instant | When this document reference was created
author | S Σ C | 1..* | 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 | S | 0..1 | Reference(ADHA Core PractitionerRole | ADHA Core Organization) | Who/what authenticated the document
custodian | S C | 0..1 | Reference(ADHA Core 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 | S 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 | S 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 | S Σ | 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 | S Σ | 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
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..* | Reference(ADHA Core Encounter) | 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(Resource) | Related identifiers or resources
Documentation for this format

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

#### 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

#### Search Parameters

None defined.