AU Core Implementation Guide
0.1.0-draft - Draft Australia flag

This page is part of the AU Core Implementation Guide 0.1.0 Draft. It is based on AU Base 4.1.0. For a full list of available versions, see the Directory of published versions

Resource Profile: AU Core DocumentReference

Official URL: http://hl7.org.au/fhir/core/StructureDefinition/au-core-documentreference Version: 0.1.0-draft
Standards status: Draft Maturity Level: 0 Computable Name: AUCoreDocumentReference

Copyright/Legal: HL7 Australia© 2018+; Licensed Under Creative Commons No Rights Reserved.

This profile sets minimum expectations for a DocumentReference resource to record, search, and fetch patient documents. It is based on the core FHIR DocumentReference resource and identifies the additional mandatory core elements, extensions, vocabularies and value sets that SHALL be present in the DocumentReference resource when conforming to this profile. It provides the floor for standards development for specific uses cases in an Australian context.

Usage scenarios

The following are supported usage scenarios for this profile:

  • Query for documents belonging to a patient
  • Query for a specific document belonging to a patient
  • Record or update a document belonging to a patient

Profile specific implementation guidance

TBD

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... identifier S1..*IdentifierOther identifiers for the document
... status S1..1codecurrent | superseded | entered-in-error
... docStatus S0..1codepreliminary | final | amended | entered-in-error
... category S1..*CodeableConceptCategorization of document
... subject S1..1Reference(AU Core Patient)Who/what is the subject of the document
... date S1..1instantWhen this document reference was created
... author S1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... description S0..1stringHuman-readable description
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
.... format S0..1CodingFormat/content rules for the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..*Reference(AU Core Encounter)Context of the document content

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..*IdentifierOther identifiers for the document
... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(AU Core Patient)Who/what is the subject of the document
... date SΣ1..1instantWhen this document reference was created
... author SΣ1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... description SΣ0..1stringHuman-readable description
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(AU Core Encounter)Context of the document content

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ1..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(AU Core Patient)Who/what is the subject of the document
... date SΣ1..1instantWhen this document reference was created
... author SΣ1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(AU Core Encounter)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... identifier S1..*IdentifierOther identifiers for the document
... status S1..1codecurrent | superseded | entered-in-error
... docStatus S0..1codepreliminary | final | amended | entered-in-error
... category S1..*CodeableConceptCategorization of document
... subject S1..1Reference(AU Core Patient)Who/what is the subject of the document
... date S1..1instantWhen this document reference was created
... author S1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... description S0..1stringHuman-readable description
... content S1..*BackboneElementDocument referenced
.... attachment S1..1AttachmentWhere to access the document
.... format S0..1CodingFormat/content rules for the document
... context S0..1BackboneElementClinical context of document
.... encounter S0..*Reference(AU Core Encounter)Context of the document content

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ1..*IdentifierOther identifiers for the document
... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(AU Core Patient)Who/what is the subject of the document
... date SΣ1..1instantWhen this document reference was created
... author SΣ1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... description SΣ0..1stringHuman-readable description
... content SΣ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(AU Core Encounter)Context of the document content

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ1..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codecurrent | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus SΣ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptKind of document (LOINC if possible)
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

... category SΣ1..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(AU Core Patient)Who/what is the subject of the document
... date SΣ1..1instantWhen this document reference was created
... author SΣ1..*Reference(AU Core PractitionerRole | AU Core Organization | AU Core System Device | AU Core Patient | AU Core RelatedPerson)Who and/or what authored the document
... authenticator S0..1Reference(AU Core PractitionerRole | AU Core Organization)Who/what authenticated the document
... custodian S0..1Reference(AU Core Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description SΣ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
.... format SΣ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context SΣ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..*Reference(AU Core Encounter)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Below is an overview of the mandatory and optional search parameters. FHIR search operations and the syntax used to describe the interactions is described here.

Name Type Conformance Description Path
TBD TBD TBD TBD TBD

Mandatory Search Parameters

The following search parameters and search parameter combinations SHALL be supported:

Optional Search Parameters

The following search parameters and search parameter combinations SHOULD be supported: