My Health Record FHIR IG
1.2.0 - active

My Health Record FHIR IG - Local Development build (v1.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

## Resource Profile: MHR DocumentReference

Official URL: http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-documentreference-mhr-1 | Version: 1.2.0
Active as of 2024-09-19 | Computable Name: MHRDocumentReference
Copyright/Legal: Copyright © 2024 Australian Digital Health Agency - All rights reserved. This content is licensed under a Creative Commons Attribution 4.0 International License. See https://creativecommons.org/licenses/by/4.0/.

The purpose of this profile is to provide a representation of a document reference for CDA documents in My Health Record. 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 is derived from the DocumentReference resource and describes the data structures and obligations to be met when conforming to this profile.

Usage:

- Refer to this Resource Profile: MHR Medical Conditions View Provenance
- Examples for this Resource Profile: DocumentReference/mcv-ds-01

### 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
masterIdentifier | SO | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO | 0..1 | code | preliminary | final | amended | entered-in-error
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
description | SO | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
attachment | SO | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO | 0..1 | Coding | Format/content rules for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
period | SO | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir

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
masterIdentifier | SO Σ | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO Σ | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO Σ | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO Σ | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO Σ | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO Σ | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
description | SO Σ | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | SO Σ | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
period | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 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).
Obligations | Actor
SHALL:handle | MHR Gateway Requester
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

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 | SO Σ | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO Σ | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO Σ | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO Σ | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO Σ | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO Σ | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 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).
Obligations | Actor
SHALL:handle | MHR Gateway Requester
sourcePatientInfo |  | 0..1 | Reference(Patient) | Patient demographics from source
related |  | 0..* | Reference(Resource) | Related identifiers or resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` from the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` from the FHIR Standard
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

This structure is derived from DocumentReference

Summary

Mandatory: 8 elements
Must-Support: 18 elements

Structures

This structure refers to these other structures:

- MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
- AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
- AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)

Differential View

This structure is derived from DocumentReference

Name | Flags | Card. | Type | Description & Constraints
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
masterIdentifier | SO | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO | 0..1 | code | preliminary | final | amended | entered-in-error
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
description | SO | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
attachment | SO | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO | 0..1 | Coding | Format/content rules for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
period | SO | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir

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
masterIdentifier | SO Σ | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO Σ | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO Σ | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO Σ | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO Σ | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO Σ | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
description | SO Σ | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | SO Σ | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
period | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 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).
Obligations | Actor
SHALL:handle | MHR Gateway Requester
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

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 | SO Σ | 1..1 | Identifier | Master Version Specific Identifier
Obligations | Actor
SHALL:handle | MHR Gateway Requester
identifier | SO Σ | 1..1 | Identifier | Other identifiers for the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
docStatus | SO Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: My Health Record Record Type (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
category | SO Σ | 1..* | CodeableConcept | Categorization of document Binding: My Health Record Record Class (extensible)
Obligations | Actor
SHALL:handle | MHR Gateway Requester
subject | SO Σ | 1..1 | Reference(MHR Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
date | SO Σ | 1..1 | instant | When this document reference was created
Obligations | Actor
SHALL:handle | MHR Gateway Requester
author | SO Σ | 1..1 | Reference(MHR Patient | AU Core Practitioner) | Who and/or what authored the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian | SO | 1..1 | Reference(AU Core Organization) | Organization which maintains the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 0..1 | string | Human-readable description
Obligations | Actor
SHALL:handle | MHR Gateway Requester
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
format | SO Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
context | SO Σ | 0..1 | BackboneElement | Clinical context of document
Obligations | Actor
SHALL:handle | MHR Gateway Requester
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 | SO Σ | 0..1 | Period | Time of service that is being documented
Obligations | Actor
SHALL:handle | MHR Gateway Requester
facilityType | SO | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
Obligations | Actor
SHALL:handle | MHR Gateway Requester
practiceSetting | SO | 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).
Obligations | Actor
SHALL:handle | MHR Gateway Requester
sourcePatientInfo |  | 0..1 | Reference(Patient) | Patient demographics from source
related |  | 0..* | Reference(Resource) | Related identifiers or resources
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.language | preferred | CommonLanguages
Additional Bindings | Purpose
AllLanguages | Max Binding
`http://hl7.org/fhir/ValueSet/languages` from the FHIR Standard
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1` from the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` from the FHIR Standard
DocumentReference.type | extensible | MyHealthRecordRecordType `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-type-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.category | extensible | MyHealthRecordRecordClass `https://healthterminologies.gov.au/fhir/ValueSet/mhr-record-class-1` from https://tx.ontoserver.csiro.au/fhir
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` from the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` from the FHIR Standard
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from `http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem`) `http://hl7.org/fhir/ValueSet/formatcodes` from the FHIR Standard
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` from the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` from the FHIR Standard

This structure is derived from DocumentReference

Summary

Mandatory: 8 elements
Must-Support: 18 elements

Structures

This structure refers to these other structures:

- MHR Patient (http://ns.electronichealth.net.au/fhir/StructureDefinition/dh-patient-mhr-1)
- AU Core Practitioner (http://hl7.org.au/fhir/core/StructureDefinition/au-core-practitioner)
- AU Core Organization (http://hl7.org.au/fhir/core/StructureDefinition/au-core-organization)

Other representations of profile: CSV, Excel, Schematron