DocumentReference Profile¶
| Canonical | ../StructureDefinition/nexus-emr-core-documentreference |
|---|---|
| Status | draft · 1.26.0 |
| Base | DocumentReference (constraint) |
| CQL primary code path | type — what this means |
| Source | FSH · 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.
Elements / Differential
What this profile constrains beyond DocumentReference. Anything not listed is unchanged from the base; muted type/cardinality values are the base's, shown for context.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | An attached document (scan, PDF, fax, Word) with its metadata and clinical context i Invariants: attachment-has-data-or-url, nexus-documentreference-subject-unless-template, nexus-documentreference-field-mapping-only-on-template |
|||
| meta | 0..1 | Meta | ||
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i |
| text | S | 0..1 | Narrative | Human-readable summary of the document reference i |
| extension | 0..* | Extension | i Slicing: value:url (open) |
|
| extension:reviewed | S | 0..* | Extension(Reviewed) | Review acknowledgement, one per reviewer (absent = unreviewed) i |
| extension:statusReason | S | 0..1 | Extension(Document Status Reason Extension) | Free-text reason the document is superseded or entered in error (absent when current) i |
| extension:fieldMapping | S | 0..1 | Extension(Form Template Field Mapping) | Fillable fields a chart value pre-fills -- form templates only i |
| identifier | 0..* | Identifier | Business identifier(s) for document reference i | |
| system | 1..1 | uri | i | |
| value | 1..1 | string | i | |
| status | S | 1..1 | code | Where the document reference is in its lifecycle i |
| type | 0..1 | CodeableConcept | Precise type of document (use category instead) i Binding: c80-doc-typecodes ( extensible) |
|
| coding | 0..* | Coding | i Slicing: pattern:system (open) |
|
| coding:loinc | S | 0..1 | Coding | LOINC document type code i |
| system | 1..1 | uri | i Fixed: http://loinc.org |
|
| code | 1..1 | code | ||
| text | 0..1 | string | Plain text representation of document type i | |
| category | S | 0..* | CodeableConcept | Document categorization (preferred over type) i |
| text | S | 0..1 | string | Plain text category description i |
| subject | S | 0..1 | Reference(Patient Profile) | The patient the document is about i |
| date | S | 0..1 | instant | When DocumentReference was created (not document date) i |
| author | S | 0..* | Reference(PractitionerRole Profile | Practitioner Profile) | Who wrote the document i |
| authenticator | S | 0..1 | Reference(PractitionerRole Profile | Practitioner Profile) | Practitioner who verified this document i |
| custodian | S | 1..1 | Reference(Organization Profile) | Organization responsible for document maintenance i |
| description | S | 0..1 | string | Human-readable description of document content i |
| content | S | 1..* | BackboneElement | Document attachment(s) -- submitted inline, stored as files, read back by URL |
| attachment | S | 1..1 | Attachment | The document: MIME type, content (inline on write / URL on read), and file metadata |
| contentType | S | 1..1 | code | MIME type (e.g., 'application/pdf') |
| language | 0..1 | code | Language of document content | |
| data | S | 0..1 | base64Binary | Base64 document content -- the UPLOAD channel; normally absent on read i |
| url | 0..1 | url | Absolute URL to the stored document -- the READ channel; set by the gateway i | |
| title | S | 0..1 | string | Document title for display |
| creation | 0..1 | dateTime | Date/time document was created | |
| context | 0..1 | BackboneElement | i | |
| encounter | S | 0..* | Reference(Encounter Profile) | Related clinical encounter(s) |
| period | S | 0..1 | Period | Time period of documented service. Only 'start' expected |
| start | S | 1..1 | dateTime | i |
| related | S | 0..* | Reference(Resource) | What this document was assembled from or sent with -- the packet, and its host i |