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DocumentReference Profile

Canonical../StructureDefinition/nexus-emr-core-documentreference
Statusdraft · 1.26.0
BaseDocumentReference (constraint)
CQL primary code pathtype — what this means
SourceFSH · JSON

Nexus EMR profile for an ATTACHED DOCUMENT -- a clinical document that exists as a file: scanned paper, incoming faxes, external consult letters received as PDF, signed consent forms, patient-uploaded files. FHIR holds the metadata and clinical context; the bytes live in document storage and are reached through content.attachment.url.

Examples

Allergy Consult Letter (challenge refuted) · Anemia Consultation Document · Cardiology Consult Letter (received) · Consent Withdrawal Evidence Document · Hrm discharge summary 20260618 · WSIB Form 8 (filed) · WSIB Form 8 Template (with field mapping)

Consent Withdrawal Evidence Document

Scanned signed AI Scribe consent withdrawal form referenced as evidence from the AI Scribe item consent

DocumentReference/nexus-emr-consent-evidence-document — claims conformance to DocumentReference Profile

{
  "resourceType": "DocumentReference",
  "id": "nexus-emr-consent-evidence-document",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-documentreference"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns="http://www.w3.org/1999/xhtml">Scanned AI Scribe consent withdrawal form signed by Avery Linwood at Cedarbrook Clinic reception on June 12, 2025. Referenced as evidence from the AI Scribe item consent (Consent/nexus-emr-item-consent-ai-scribe-declined-evidence).</div>"
  },
  "identifier": [
    {
      "use": "secondary",
      "system": "../NamingSystem/cedarbrook-clinic-documentreference-raw-code",
      "value": "EMR-docref-avery-consent-withdrawal-20250612"
    }
  ],
  "status": "current",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "59284-0",
        "display": "Consent Document"
      }
    ],
    "text": "Signed AI Scribe consent withdrawal form"
  },
  "category": [
    {
      "text": "Consent and authorization documents"
    }
  ],
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-06-12T09:20:00-06:00",
  "description": "Consent withdrawal form signed by the patient at reception, withdrawing her consent for AI scribe use during visits.",
  "custodian": {
    "reference": "Organization/cedarbrook-clinic"
  },
  "content": [
    {
      "attachment": {
        "contentType": "application/pdf",
        "language": "en-CA",
        "title": "AI Scribe Consent Withdrawal Form - Signed - June 12, 2025",
        "creation": "2025-06-12T09:15:00-06:00",
        "size": 243,
        "data": "JVBERi0xLjQKJeLjz9MKMSAwIG9iago8PAovVHlwZSAvQ2F0YWxvZwovUGFnZXMgMiAwIFIKPj4KZW5kb2JqCjIgMCBvYmoKPDwKL1R5cGUgL1BhZ2VzCi9LaWRzIFszIDAgUl0KL0NvdW50IDEKPD4KZW5kb2JqCjMgMCBvYmoKPDwKL1R5cGUgL1BhZ2UKL1BhcmVudCAyIDAgUgovTWVkaWFCb3ggWzAgMCA2MTIgNzkyXQovUmVzb3VyY2VzIDw8L0ZvbnQgPDwvRjEgNCAwIFI+Pj4+Ci9Db250ZW50cyA1IDAgUgo+PgplbmRvYmoK"
      }
    }
  ]
}

Referenced by: Nexus EMR Item Consent - AI Scribe DECLINED With Evidence Example · nexus-privacy-directive-lockbox-named-record