eHealth Infrastructure
3.2.0 - release

This page is part of the FUT Infrastructure (v3.2.0: Release) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: ehealth-documentreference

Official URL: http://ehealth.sundhed.dk/fhir/StructureDefinition/ehealth-documentreference Version: 3.2.0
Active as of 2024-09-02 Computable Name: ehealth-documentreference

Introduction

A DocumentReference resource is used to describe a document that is made available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be displayed to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type and that conforms to this definition.

Typically, DocumentReference resources are used in document indexing systems, such as IHE XDS , and are used to refer to:

  • CDA documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents , and even digital records of faxes where sufficient information is available
  • Other kinds of documents, such as records of prescriptions

Scope and Usage

In scope of the eHealth infrastructure the primary use of the DocumentReference resource is to contain or refer to information material used in relation to PlanDefinition and Questionnaire. This information material can be in the form of embedded material (of limited size) or references to videos, PDF-files or printed material.

See eHealth-plandefinition for further details.

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 DocumentReference
... type 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type (required)
... category 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} Organization which maintains the document
... relatesTo
.... target 1..1 Reference(ehealth-documentreference) Target of the relationship
... content
.... format 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)
... context
.... event 0..* CodeableConcept Main clinical acts documented
Binding: Event Type Codes (required)
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Codes (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Codes (required)
.... sourcePatientInfo 0..1 Reference(ehealth-patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG
DocumentReference.context.eventrequiredEventTypeCodes
http://ehealth.sundhed.dk/vs/event-type-codes
from this IG
DocumentReference.context.facilityTyperequiredFacilityTypeCodes
http://ehealth.sundhed.dk/vs/facility-type-codes
from this IG
DocumentReference.context.practiceSettingrequiredPracticeSettingCodes
http://ehealth.sundhed.dk/vs/practice-setting-codes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

... category Σ 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject Σ 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... author Σ 0..* Reference(ehealth-practitioner | ehealth-organization | ehealth-device | ehealth-patient | ehealth-relatedperson) {r} Who and/or what authored the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} Organization which maintains the document
... content Σ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Where to access the document
.... format Σ 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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: Document Type (required)
... category Σ 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject Σ 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... date Σ 0..1 instant When this document reference was created
... author Σ 0..* Reference(ehealth-practitioner | ehealth-organization | ehealth-device | ehealth-patient | ehealth-relatedperson) {r} Who and/or what authored the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} 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(ehealth-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 Σ 1..1 Attachment Where to access the document
.... format Σ 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)
... context 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 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: Event Type Codes (required)
.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Codes (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Codes (required)
.... sourcePatientInfo 0..1 Reference(ehealth-patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG
DocumentReference.context.eventrequiredEventTypeCodes
http://ehealth.sundhed.dk/vs/event-type-codes
from this IG
DocumentReference.context.facilityTyperequiredFacilityTypeCodes
http://ehealth.sundhed.dk/vs/facility-type-codes
from this IG
DocumentReference.context.practiceSettingrequiredPracticeSettingCodes
http://ehealth.sundhed.dk/vs/practice-setting-codes
from this IG

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference DocumentReference
... type 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Type (required)
... category 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} Organization which maintains the document
... relatesTo
.... target 1..1 Reference(ehealth-documentreference) Target of the relationship
... content
.... format 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)
... context
.... event 0..* CodeableConcept Main clinical acts documented
Binding: Event Type Codes (required)
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Codes (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Codes (required)
.... sourcePatientInfo 0..1 Reference(ehealth-patient) Patient demographics from source

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG
DocumentReference.context.eventrequiredEventTypeCodes
http://ehealth.sundhed.dk/vs/event-type-codes
from this IG
DocumentReference.context.facilityTyperequiredFacilityTypeCodes
http://ehealth.sundhed.dk/vs/facility-type-codes
from this IG
DocumentReference.context.practiceSettingrequiredPracticeSettingCodes
http://ehealth.sundhed.dk/vs/practice-setting-codes
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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.

... category Σ 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject Σ 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... author Σ 0..* Reference(ehealth-practitioner | ehealth-organization | ehealth-device | ehealth-patient | ehealth-relatedperson) {r} Who and/or what authored the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} Organization which maintains the document
... content Σ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment Σ 1..1 Attachment Where to access the document
.... format Σ 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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
... 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: Document Type (required)
... category Σ 0..1 CodeableConcept Categorization of document
Binding: Document Class (required)
... subject Σ 0..1 Reference(ehealth-patient | ehealth-practitioner | Group | ehealth-device) {r} Who/what is the subject of the document
... date Σ 0..1 instant When this document reference was created
... author Σ 0..* Reference(ehealth-practitioner | ehealth-organization | ehealth-device | ehealth-patient | ehealth-relatedperson) {r} Who and/or what authored the document
... authenticator 0..1 Reference(ehealth-practitioner | ehealth-organization) {r} Who/what authenticated the document
... custodian 0..1 Reference(ehealth-organization) {r} 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(ehealth-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 Σ 1..1 Attachment Where to access the document
.... format Σ 0..1 Coding Format/content rules for the document
Binding: FormatCodes (required)
... context 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 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: Event Type Codes (required)
.... period Σ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Codes (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Codes (required)
.... sourcePatientInfo 0..1 Reference(ehealth-patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentType
http://ehealth.sundhed.dk/vs/document-type
from this IG
DocumentReference.categoryrequiredDocumentClass
http://ehealth.sundhed.dk/vs/document-class
from this IG
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatrequiredFormatCodes
http://ehealth.sundhed.dk/vs/format-codes
from this IG
DocumentReference.context.eventrequiredEventTypeCodes
http://ehealth.sundhed.dk/vs/event-type-codes
from this IG
DocumentReference.context.facilityTyperequiredFacilityTypeCodes
http://ehealth.sundhed.dk/vs/facility-type-codes
from this IG
DocumentReference.context.practiceSettingrequiredPracticeSettingCodes
http://ehealth.sundhed.dk/vs/practice-setting-codes
from this IG

 

Other representations of profile: CSV, Excel, Schematron