AU eRequesting Implementation Guide
1.0.0 - Working Standard

AU eRequesting Implementation Guide - Downloaded Version 1.0.0 See the Directory of published versions

## Resource Profile: AU eRequesting Clinical Context DocumentReference

Official URL: http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-clinicalcontext-documentreference | Version: 1.0.0
Standards status: Trial-use | Maturity Level: 1 | Computable Name: AUeRequestingClinicalContextDocumentReference
Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License. HL7 Australia© 2024+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for representing clinical context using a DocumentReference resource to record, search, and fetch clinical context narrative information that provides an overview of the individual's current clinical situation associated with a requested service. Clinical context is intended to describe the broader clinical background or circumstances relating to the request, supporting the service provider in making informed decisions about service delivery. It is based on the DocumentReference resource and identifies the additional constraints, extensions, vocabularies and value sets that SHALL be present in the DocumentReference when conforming to this profile.

### Profile Specific Implementation Guidance

- Clinical context is to be implemented as unformatted text narrative representing the broader clinical background or circumstances related to a request, not general comments or administrative notes.

Usages:

- Refer to this Profile: AU eRequesting Diagnostic Request
- Examples for this Profile: DocumentReference/documentreference-clinical-context
- CapabilityStatements using this Profile: AU eRequesting Filler CapabilityStatement, AU eRequesting Patient CapabilityStatement, AU eRequesting Placer CapabilityStatement and AU eRequesting Server CapabilityStatement

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subject | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO Σ | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
contentType | SO Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | preferred | Document Type Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DocumentReference

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
status | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
subject | SO | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
attachment | SO | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
contentType | SO | 1..1 | code | Mime type of the content, with charset etc. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 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 | Σ | 0..1 | Identifier | Master Version Specific Identifier
identifier | Σ | 0..* | Identifier | Other identifiers for the document
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO Σ | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship
description | Σ | 0..1 | string | Human-readable description
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | SO Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
url | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
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: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | Time of service that is being documented
facilityType |  | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting |  | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo |  | 0..1 | Reference(Patient) | Patient demographics from source
related |  | 0..* | Reference(Resource) | Related identifiers or resources
Documentation for this format

#### Terminology Bindings

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 | preferred | Document Type Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.category | Base | example | Document Class Value Set | 📍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.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DocumentReference.content.​format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std.
DocumentReference.context.​event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.0
DocumentReference.context.​facilityType | Base | example | Facility Type Code Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.context.​practiceSetting | Base | example | Practice Setting Code Value Set | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DocumentReference

Summary

Mandatory: 4 elements
Must-Support: 9 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- AU eRequesting Patient (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-patient)
- AU eRequesting Practitioner (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-practitioner)
- AU eRequesting PractitionerRole (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-practitionerrole)
- AU eRequesting Organization (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)

Maturity: 1

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
subject | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO Σ | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
contentType | SO Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

#### Terminology Bindings

Path | Status | Usage | ValueSet | Version | Source
DocumentReference.status | Base | required | DocumentReferenceStatus | 📍4.0.1 | FHIR Std.
DocumentReference.type | Base | preferred | Document Type Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

Differential View

This structure is derived from DocumentReference

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | DocumentReference | A reference to a document
status | SO | 1..1 | code | current | superseded | entered-in-error
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
type | SO | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
subject | SO | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
content | SO | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
attachment | SO | 1..1 | Attachment | Where to access the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
contentType | SO | 1..1 | code | Mime type of the content, with charset etc. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
Documentation for this format

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
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 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 | Σ | 0..1 | Identifier | Master Version Specific Identifier
identifier | Σ | 0..* | Identifier | Other identifiers for the document
status | ?!SO Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | SO Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
coding |  | 1..* | Coding | Code defined by a terminology system Fixed Value: (Complex)
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
system |  | 1..1 | uri | Identity of the terminology system Fixed Value: http://loinc.org
version |  | 0..1 | string | Version of the system - if relevant
code |  | 1..1 | code | Symbol in syntax defined by the system Fixed Value: 107903-7
display |  | 0..1 | string | Representation defined by the system
userSelected |  | 0..1 | boolean | If this coding was chosen directly by the user
text |  | 0..1 | string | Plain text representation of the concept
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject | SO Σ | 1..1 | Reference(AU eRequesting Patient) | Who/what is the subject of the document
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
date | SO Σ | 0..1 | instant | When this document reference was created
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
author | SO Σ | 0..* | Reference(AU eRequesting Patient | AU eRequesting Practitioner | AU eRequesting PractitionerRole | AU eRequesting Organization | AU Core RelatedPerson | Device) | Who and/or what authored the document
Obligations | Actor
SHALL:populate-if-known | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
code | Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship
description | Σ | 0..1 | string | Human-readable description
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | SO Σ | 1..* | BackboneElement | Document referenced
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
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:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url
contentType | SO Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Fixed Value: text/plain
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | SO | 1..1 | base64Binary | Data inline, base64ed
Obligations | Actor
SHALL:populate | AU eRequesting Placer
SHALL:handle | AU eRequesting Filler
SHALL:handle | AU eRequesting Server
SHALL:able-to-populate | AU eRequesting Server
SHALL:no-error | AU eRequesting Patient
url | Σ | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size | Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided)
hash | Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed)
title | Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo
creation | Σ | 0..1 | dateTime | Date attachment was first created
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
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: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period | Σ | 0..1 | Period | Time of service that is being documented
facilityType |  | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting |  | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
sourcePatientInfo |  | 0..1 | Reference(Patient) | Patient demographics from source
related |  | 0..* | Reference(Resource) | Related identifiers or resources
Documentation for this format

#### Terminology Bindings

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 | preferred | Document Type Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.category | Base | example | Document Class Value Set | 📍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.​attachment.contentType | Base | required | MimeType | 📍4.0.1 | FHIR Std.
DocumentReference.content.​attachment.language | Base | preferred | Common Languages | 📍4.0.1 | FHIR Std.
DocumentReference.content.​format | Base | preferred | DocumentReference Format Code Set | 📍4.0.1 | FHIR Std.
DocumentReference.context.​event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.0
DocumentReference.context.​facilityType | Base | example | Facility Type Code Value Set | 📍4.0.1 | FHIR Std.
DocumentReference.context.​practiceSetting | Base | example | Practice Setting Code Value Set | 📍4.0.1 | FHIR Std.

#### Constraints

Id | Grade | Path(s) | Description | Expression
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources | `contained.contained.empty()`
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource | `contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()`
dom-4 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated | `contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()`
dom-5 | error | DocumentReference | If a resource is contained in another resource, it SHALL NOT have a security label | `contained.meta.security.empty()`
dom-6 | best practice | DocumentReference | A resource should have narrative for robust management | `text.`div`.exists()`
ele-1 | error | **ALL** elements | All FHIR elements must have a @value or children | `hasValue() or (children().count() > id.count())`
ext-1 | error | **ALL** extensions | Must have either extensions or value[x], not both | `extension.exists() != value.exists()`

This structure is derived from DocumentReference

Summary

Mandatory: 4 elements
Must-Support: 9 elements
Fixed: 1 element

Structures

This structure refers to these other structures:

- AU eRequesting Patient (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-patient)
- AU eRequesting Practitioner (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-practitioner)
- AU eRequesting PractitionerRole (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-practitionerrole)
- AU eRequesting Organization (http://hl7.org.au/fhir/ereq/StructureDefinition/au-erequesting-organization)
- AU Core RelatedPerson (http://hl7.org.au/fhir/core/StructureDefinition/au-core-relatedperson)

Maturity: 1

Other representations of profile: CSV, Excel, Schematron

### Notes:

Below is an overview of the mandatory and optional search parameters and combined search parameters. See the AU eRequesting CapabilityStatements for a complete list of supported RESTful interactions for this IG.

FHIR search operations are described here and the syntax used to describe AU eRequesting interactions is defined here.

Any search parameter defined in FHIR may be 'allowed' by the system unless explicitly marked as "SHALL NOT".

Parameter(s) | Server Conformance | Placer Conformance | Filler Conformance | Patient Conformance | Type(s) | Requirements (when used alone or in combination)
--- | --- | --- | --- | --- | --- | ---
_id | SHALL | MAY | MAY | MAY | `token` |

#### Search Parameters:

The following search parameters and search parameter combinations are supported. Conformance obligations are detailed in the table above.

1. `_id` search parameter

   `GET [base]/DocumentReference?_id=[id]`

   Example:

   1. GET [base]/DocumentReference?_id=123654

Implementation Notes: Fetches a bundle with the requested DocumentReference, instead of just the resource itself, and allows for the inclusion of additional search parameters such as _include, _revinclude, or _lastUpdated (how to search by id of the resource)