Medtech ALEX® AU Implementation Guide - Local Development build (v1.0.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: Consultation Notes IPS Profile

The Consultation Notes for IPS

Usages:

• Use this Profile: Bundle - IPS (AU)

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..*	AlexConsultationNotes	A reference to a document
meta	SΣ	1..1	Meta	Metadata about the resource
lastUpdated	SΣ	0..1	instant	When the resource version last changed
profile	SΣ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
coding	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Consult Note
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
content	SΣ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Where to access the document
contentType	SΣ	0..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. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
format	SΣ	0..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
system	SΣ	0..1	uri	Identity of the terminology system
code	SΣ	0..1	code	Symbol in syntax defined by the system
context	SΣ	1..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
period	Σ	1..1	Period	Time of service that is being documented
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
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.
DocumentReference.content.​format	Base	required	Consultation Note Content Format Value Set	📦1.0.0	This IG

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 AlexConsultationNotes

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	AlexConsultationNotes	A reference to a document
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	AlexConsultationNotes	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	SΣ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required)
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Consult Note
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Reference to Patient resource
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	External Name of Patient
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Reference to Practitioner resource
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	External Name of Practitioner
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	SΣ	1..*	BackboneElement	Document referenced
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	SΣ	1..1	Attachment	Where to access the document
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	SΣ	0..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. Example General: text/plain; charset=UTF-8, image/png
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	S	0..1	base64Binary	Data inline, base64ed
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	SΣ	0..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
context	SΣ	1..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	1..1	Period	Time of service that is being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
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.meta.​security	Base	required	Definition of Confidentiality Value Set	📦1.0.0	This IG
DocumentReference.meta.​tag	Base	example	Common Tags	📍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.subject.​type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
DocumentReference.author.​type	Base	extensible	ResourceType	📍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	required	Consultation Note Content Format Value Set	📦1.0.0	This IG
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v5.5
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 AlexConsultationNotes

Summary

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	AlexConsultationNotes	A reference to a document
meta	SΣ	1..1	Meta	Metadata about the resource
lastUpdated	SΣ	0..1	instant	When the resource version last changed
profile	SΣ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
coding	SΣ	1..1	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Consult Note
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
content	SΣ	1..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Where to access the document
contentType	SΣ	0..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. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
format	SΣ	0..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
system	SΣ	0..1	uri	Identity of the terminology system
code	SΣ	0..1	code	Symbol in syntax defined by the system
context	SΣ	1..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
period	Σ	1..1	Period	Time of service that is being documented
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
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.
DocumentReference.content.​format	Base	required	Consultation Note Content Format Value Set	📦1.0.0	This IG

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 AlexConsultationNotes

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	AlexConsultationNotes	A reference to a document
Documentation for this format

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	AlexConsultationNotes	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	SΣ	1..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	SΣ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	SΣ	1..1	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required)
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	1..1	Coding	Code defined by a terminology system
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Consult Note
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Reference to Patient resource
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	External Name of Patient
date	SΣ	0..1	instant	When this document reference was created
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Reference to Practitioner resource
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	External Name of Practitioner
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	SΣ	1..*	BackboneElement	Document referenced
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	SΣ	1..1	Attachment	Where to access the document
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	SΣ	0..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. Example General: text/plain; charset=UTF-8, image/png
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	S	0..1	base64Binary	Data inline, base64ed
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	SΣ	0..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	0..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	0..1	code	Symbol in syntax defined by the system
display	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
context	SΣ	1..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	1..1	Period	Time of service that is being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	1..1	dateTime	Starting time with inclusive boundary
end	ΣC	0..1	dateTime	End time with inclusive boundary, if not ongoing
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.meta.​security	Base	required	Definition of Confidentiality Value Set	📦1.0.0	This IG
DocumentReference.meta.​tag	Base	example	Common Tags	📍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.subject.​type	Base	extensible	ResourceType	📍4.0.1	FHIR Std.
DocumentReference.author.​type	Base	extensible	ResourceType	📍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	required	Consultation Note Content Format Value Set	📦1.0.0	This IG
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v5.5
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 AlexConsultationNotes

Summary

Other representations of profile: CSV, Excel, Schematron