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 / Key elements
The working view: must-support, required, modifier and sliced elements from the effective (snapshot) definition.
| Element | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference | 0..* | An attached document (scan, PDF, fax, Word) with its metadata and clinical context i Invariants: dom-2, dom-3, dom-4, dom-5, dom-6, attachment-has-data-or-url, nexus-documentreference-subject-unless-template, nexus-documentreference-field-mapping-only-on-template |
||
| meta | 0..1 | Meta | Metadata about the resource Invariants: ele-1 |
|
| source | S | 0..1 | uri | Identifies EMR instance & pipeline version the resource came from i Invariants: ele-1 |
| implicitRules | ?! | 0..1 | uri | A set of rules under which this content was created i Invariants: ele-1 |
| text | S | 0..1 | Narrative | Human-readable summary of the document reference i Invariants: ele-1 |
| extension:reviewed | S | 0..* | Extension(Reviewed) | Review acknowledgement, one per reviewer (absent = unreviewed) i Invariants: ele-1, ext-1 |
| extension:statusReason | S | 0..1 | Extension(Document Status Reason Extension) | Free-text reason the document is superseded or entered in error (absent when current) i Invariants: ele-1, ext-1 |
| extension:fieldMapping | S | 0..1 | Extension(Form Template Field Mapping) | Fillable fields a chart value pre-fills -- form templates only i Invariants: ele-1, ext-1 |
| identifier | 0..* | Identifier | Business identifier(s) for document reference i Invariants: ele-1 |
|
| use | ?! | 0..1 | code | usual | official | temp | secondary | old (If known) i Binding: identifier-use ( required)Invariants: ele-1 |
| system | 1..1 | uri | The namespace for the identifier value i Invariants: ele-1 |
|
| value | 1..1 | string | The value that is unique i Invariants: ele-1 |
|
| status | S ?! | 1..1 | code | Where the document reference is in its lifecycle i Binding: document-reference-status ( required)Invariants: ele-1 |
| type | 0..1 | CodeableConcept | Precise type of document (use category instead) i Binding: c80-doc-typecodes ( extensible)Invariants: ele-1 |
|
| coding:loinc | S | 0..1 | Coding | LOINC document type code i Invariants: ele-1 |
| system | 1..1 | uri | Identity of the terminology system i Fixed: http://loinc.orgInvariants: ele-1 |
|
| code | 1..1 | code | Symbol in syntax defined by the system Invariants: ele-1 |
|
| category | S | 0..* | CodeableConcept | Document categorization (preferred over type) i Binding: document-classcodes ( example)Invariants: ele-1 |
| text | S | 0..1 | string | Plain text category description i Invariants: ele-1 |
| subject | S | 0..1 | Reference(Patient Profile) | The patient the document is about i Invariants: ele-1 |
| date | S | 0..1 | instant | When DocumentReference was created (not document date) i Invariants: ele-1 |
| author | S | 0..* | Reference(PractitionerRole Profile | Practitioner Profile) | Who wrote the document i Invariants: ele-1 |
| authenticator | S | 0..1 | Reference(PractitionerRole Profile | Practitioner Profile) | Practitioner who verified this document i Invariants: ele-1 |
| custodian | S | 1..1 | Reference(Organization Profile) | Organization responsible for document maintenance i Invariants: ele-1 |
| relatesTo | 0..* | BackboneElement | Relationships to other documents i Invariants: ele-1 |
|
| code | 1..1 | code | replaces | transforms | signs | appends i Binding: document-relationship-type ( required)Invariants: ele-1 |
|
| target | 1..1 | Reference(DocumentReference) | Target of the relationship Invariants: ele-1 |
|
| description | S | 0..1 | string | Human-readable description of document content i Invariants: ele-1 |
| content | S | 1..* | BackboneElement | Document attachment(s) -- submitted inline, stored as files, read back by URL Invariants: ele-1 |
| attachment | S | 1..1 | Attachment | The document: MIME type, content (inline on write / URL on read), and file metadata Invariants: ele-1 |
| contentType | S | 1..1 | code | MIME type (e.g., 'application/pdf') Binding: mimetypes ( required)Invariants: ele-1 |
| data | S | 0..1 | base64Binary | Base64 document content -- the UPLOAD channel; normally absent on read i Invariants: ele-1 |
| title | S | 0..1 | string | Document title for display Invariants: ele-1 |
| context | 0..1 | BackboneElement | Clinical context of document i Invariants: ele-1 |
|
| encounter | S | 0..* | Reference(Encounter Profile) | Related clinical encounter(s) Invariants: ele-1 |
| period | S | 0..1 | Period | Time period of documented service. Only 'start' expected Invariants: ele-1 |
| start | S | 1..1 | dateTime | Starting time with inclusive boundary i Invariants: ele-1 |
| related | S | 0..* | Reference(Resource) | What this document was assembled from or sent with -- the packet, and its host i Invariants: ele-1 |