NHS North West Genomics
2.2.5 - ci-build
NHS North West Genomics
2.2.5 - ci-build
NHS North West Genomics - Local Development build (v2.2.5) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://fhir.nwgenomics.nhs.uk/StructureDefinition/DocumentReference | Version: 2.2.5 | ||||
| Draft as of 2026-11-05 | Computable Name: DocumentReference | ||||
Health Document
For HL7 v2 MDM T02, see HL7 v2 MDM T02 Mapping
| IHE XDS Document Entry | IHE MHD FHIR DocumentReference | HL7 v2 | Use | Description | NHS Data Dictionary |
|---|---|---|---|---|---|
| uniqueId | masterIdentifier / identifier | TXA-12 | Primary Query | The globally unique identifier assigned by the document creator to this document. This unique identifier may be used in the body of other documents to reference this document. The structure and format of this Id is consistent with the document content Interoperability Specification, in particular with the formatCode attribute. Has a single value. | |
| entryUUID | identifier | Technical | This globally unique identifier is primarily intended foruse as a document registry management identifier. It is not meant to be an external reference (outside of the Document Registry) for documents (e.g., in links within other documents) | ||
| availabilityStatus | status | Primary Query | |||
| type | type | TXA-2 | Secondary Filtering | The code specifying the precise type of document from the user perspective (e.g. Pulmonary History and Physical, Discharge Summary, Ultrasound Report). | DocumentEntry Type |
| class | category | TXA-24 | Primary Query | The code specifying the high-level use classification of the document type (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow). The code specifying the particular kind of document. Shall have a single value. Coded with a coarse level of granularity. | DocumentEntry Class |
| patientId | subject | PID-3 | Primary Query | The patientId represents the subject of care of the document. It contains the Health ID with its two parts: Authority Domain Id (OID/System Uri enforced by the Registry) An Id in the above domain issued by the PDQ Supplier Actor (NHS England PAS) | NHS Number |
| author | author | TXA-5 | Secondary Filtering | The humans and/or machines that authored the document. | Organisation Code CONSULTANT + GMP Code |
| creationTime | content.attachment.date | Secondary Filtering | |||
| title | content.attachment.title | TXA-25 | Secondary Filtering | Represents the title of the document | |
| comments | description | Secondary Filtering | Comments associated with the Document. | ||
| confidentialityCode | securityLabel | TXA-18 | Primary Query | The code specifying the level of confidentiality of the document. Has one or more values. | |
referenceIdList urn:ihe:iti:xds:2015:encounterId |
context.encounter | PV1-19 | Hospital Provider Spell Identifier | ||
| eventCodeList | context.event | Primary Query | This list of codes represents the main clinical “key words” for queries specific to certain document content (e.g. test panel code for laboratory results).The value chosen shall not conflict with the values selected in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This value list may have zero or more values. | ||
| serviceStartTime and serviceStopTime | context.period | TXA-4 | Primary Query | Represents the start and stop time the service being documented took place (clinically significant, but not necessarily when the document was produced or approved). | |
| practiceSettingCode | context.practiceSetting | PV1-10 | Primary Query | This code represents the type of organizational setting of the clinical encounter during which the documented act occurred. The code specifying the clinical specialty where the act that resulted in the document was performed (e.g., Intensive care, Laboratory, Radiology). Coarse level of granularity. Has a single value | Main Specialty Code OID 2.16.840.1.113883.2.1.6.8 |
| healthcareFacilityTypeCode | context.facilityType | Primary Query | This code represents the type of organization where the clinical encounter during which the documented act occurred. The value chosen in the value set needs to avoid conflict with the value used in the typeCode, as such a conflict would create an ambiguous situation. Has a single value. | ACTIVITY LOCATION TYPE CODE | |
| sourcePatientInfo and sourcePatientId | context.sourcePatientInfo | PID-3 | The sourcePatientId represents the subject of care medical record Identifier (e.g., Patient Id) in the local patientIdentifier Domain of the Document Source. If used, it contains two parts:Authority Domain Id (System Uri/OID) and an Id in the local domain (e.g., Patient Id). It is only intended as an audit/checking mechanism and has occasional use for Document Consumer Actors. | Medical Record Number | |
| referenceIdList | context.related[DiagnosticReport] | ORC-2 OBR-3 SPM-30 (via DiagnosticReport) |
Primary Query | In XDS this list contains zero or more Identifiers (e.g. Accession Numbers, Order Numbers, Report Identifiers). In this profile these identifiers are not repeated on the DocumentReference; instead context.related holds a reference to the DiagnosticReport which carries them. This reference is optional but highly recommended for the Document Access Provider when serving laboratory or imaging reports. |
DiagnosticReport Accession Number - DiagnosticReport.specimen Order Identifier - DiagnosticReport.basedOn Report Identifier - DiagnosticReport.identifier |
| mimeType | content.attachment.contentType | OBX-5 ED-3 | Technical | MIME type of the document in the Repository. Shall have a single value | |
| URI | content.attachment.uri | OBX-5 (RP) | Technical | The URI for the document | |
| languageCode | content.attachment.language | Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066. Has a single value. | |||
| formatCode | content.format | Technical | Code globally uniquely specifying the format of the document. Along with the typeCode, it provides sufficient information to allow any potential Document Consumer to know if it will be able to process/display the document by identifying an encoding, structure and template | ||
| hash | content.attachment.hash | Technical | Hash key of the document itself. This value is computed by the Document Repository and used by the Document Registry for detecting tampering or the improper resubmission of documents .Has a single value | ||
| size | content.attachment.size | Technical | Size in bytes of the byte stream of the document | ||
| legalAuthenticator | authenticator | Represents a participant within an authorInstitution who has legally authenticated or attested the document. Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator. This attribute may be absent if not applicable. If present, shall have a single value | |||
| Associations | relatesTo | Relationships to other documents | |||
| Associations type | relatesTo.code | ||||
| Associations reference | relatesTo.target | ||||
| objectType | The type of DocumentEntry (e.g. On-Demand DocumentEntry) |
Usages:
You can also check for usages in the FHIR IG Statistics
Description Differentials, Snapshots, and other representations.
| Name | Flags | Card. | Type | Description & Constraints Filter:  | ||||
|---|---|---|---|---|---|---|---|---|
  DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
 identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
 subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
  identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| identifier |
0..1 | PractitionerIdentifier  , OrganisationCode |
Logical reference, when literal reference is not known | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| content |
1..* | BackboneElement | Document referenced | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| context |
0..1 | BackboneElement | Clinical context of document | |||||
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
 Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
  related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
 reference |
C | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
 type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Required Pattern: DiagnosticReport (extensions allowed) | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.5 |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
| DocumentReference.context.related:DiagnosticReport.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
 type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
| identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| identifier |
0..1 | PractitionerIdentifier, OrganisationCode | Logical reference, when literal reference is not known | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| content |
||||||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| context |
||||||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
| Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
| related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
| reference |
1..1 | string | Literal reference, Relative, internal or absolute URL | |||||
| type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Required Pattern: DiagnosticReport (extensions allowed) | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
 extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| masterIdentifier |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | PractitionerIdentifier , OrganisationCode |
Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
1..* | BackboneElement | Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| context |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
| related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Required Pattern: DiagnosticReport (extensions allowed) | |||||
| identifier |
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.author.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.encounter.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.5 |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
| DocumentReference.context.sourcePatientInfo.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.related:DiagnosticReport.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
| identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| identifier |
0..1 | PractitionerIdentifier , OrganisationCode |
Logical reference, when literal reference is not known | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| content |
1..* | BackboneElement | Document referenced | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| context |
0..1 | BackboneElement | Clinical context of document | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
| Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
| related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
| reference |
C | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Required Pattern: DiagnosticReport (extensions allowed) | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.5 |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
| DocumentReference.context.related:DiagnosticReport.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
Differential View
This structure is derived from DocumentReference
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
| type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
| identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| identifier |
0..1 | PractitionerIdentifier, OrganisationCode | Logical reference, when literal reference is not known | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| content |
||||||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| context |
||||||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
| Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
| related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
| reference |
1..1 | string | Literal reference, Relative, internal or absolute URL | |||||
| type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Required Pattern: DiagnosticReport (extensions allowed) | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
Snapshot ViewView
| Name | Flags | Card. | Type | Description & Constraints Filter: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | DocumentReference | A reference to a document | |||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |||||
| masterIdentifier |
0..1 | Identifier | Master Version Specific Identifier | |||||
| identifier |
1..* | CorrelationIdentifier | Other identifiers for the document | |||||
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | |||||
| type |
0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentEntry Type (required) | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: DocumentEntry Class (required) | |||||
| subject |
1..1 | Reference(Patient) | Who/what is the subject of the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | NHSIdentifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| date |
1..1 | instant | When this document reference was created | |||||
| author |
0..* | Reference(Organization | Practitioner | PractitionerRole) | Who and/or what authored the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | PractitionerIdentifier , OrganisationCode |
Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | OrganisationCode | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
0..1 | string | Human-readable description | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
1..* | BackboneElement | Document referenced | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
1..1 | NWAttachment | Where to access the document | |||||
| format |
0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | |||||
| context |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| encounter |
0..1 | Reference(Encounter) | Context of the document content | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | CorrelationIdentifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| event |
0..* | CodeableConcept | The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.) Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
0..1 | Period | Time of service that is being documented | |||||
| facilityType |
0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |||||
| practiceSetting |
0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |||||
| sourcePatientInfo |
0..1 | Reference(Patient) | Patient demographics from source | |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 0..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
0..1 | MedicalRecordNumber | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| Slices for related |
0..* | Reference(Resource) | Related resources. For laboratory and imaging reports, a reference to the DiagnosticReport Slice: Unordered, Open by value:type | |||||
| related:DiagnosticReport |
0..1 | Reference(Diagnostic Report) | The DiagnosticReport this document is a rendering of (laboratory or imaging report)
| |||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
C | 1..1 | string | Literal reference, Relative, internal or absolute URL | ||||
| type |
1..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). Required Pattern: DiagnosticReport (extensions allowed) | |||||
| identifier |
0..1 | Identifier | Logical reference, when literal reference is not known | |||||
| display |
0..1 | string | Text alternative for the resource | |||||
| Documentation for this format | ||||||||
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.docStatus | Base | required | CompositionStatus | 📍4.0.1 | FHIR Std. |
| DocumentReference.type | Base | required | DocumentEntry Type | 📦2.2.5 | This IG |
| DocumentReference.category | Base | required | DocumentEntry Class | 📦2.2.5 | This IG |
| DocumentReference.subject.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.author.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | required | DocumentRelationshipType | 📍4.0.1 | FHIR Std. |
| DocumentReference.securityLabel | Base | extensible | SecurityLabels | 📍4.0.1 | FHIR Std. |
| DocumentReference.content.format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.encounter.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.5 |
| DocumentReference.context.facilityType | Base | required | Facility Type | 📦2.2.5 | This IG |
| DocumentReference.context.practiceSetting | Base | required | Specialty | 📦2.2.5 | This IG |
| DocumentReference.context.sourcePatientInfo.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| DocumentReference.context.related:DiagnosticReport.type | Base | extensible | ResourceType | 📍4.0.1 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| Name | Document Access Provider |
|---|---|
| DocumentReference |
|
| context |
|
| Slices for related |
|
| related:DiagnosticReport |
|
| Documentation for this format | |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements(2 nested mandatory elements)
Must-Support: 7 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron