Medtech ALEX® Implementation Guide - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

• Content
• Detailed Descriptions
• Examples
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Resource Profile: Consultation Notes Profile

The Consultation Notes exposed by ALEX

Usage:

• Derived from this Resource Profile: Consultation Notes IPS Profile
• Use this Resource Profile: Consultation Notes Bundle
• Examples for this Resource Profile: DocumentReference/consultationNotes-full-example and DocumentReference/consultationNotes-min-example

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
DocumentReference		0..*	DocumentReference	A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
meta	Σ	0..1	Meta	Metadata about the resource ele-1: All FHIR elements must have a @value or children
lastUpdated	SΣ	0..1	instant	When the resource version last changed ele-1: All FHIR elements must have a @value or children
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required) ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children Required Pattern: current
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
reference	ΣC	0..1	string	Reference to Patient resource ele-1: All FHIR elements must have a @value or children
display	Σ	0..1	string	External Name of Patient ele-1: All FHIR elements must have a @value or children
date	SΣ	0..1	instant	When this document reference was created ele-1: All FHIR elements must have a @value or children
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document ele-1: All FHIR elements must have a @value or children
reference	ΣC	0..1	string	Reference to Practitioner resource ele-1: All FHIR elements must have a @value or children
display	Σ	0..1	string	External Name of Practitioner ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
contentType	SΣ	1..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. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
data	S	1..1	base64Binary	Data inline, base64ed ele-1: All FHIR elements must have a @value or children
format	SΣ	1..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required) ele-1: All FHIR elements must have a @value or children
system	SΣ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
context	SΣ	1..1	BackboneElement	Clinical context of document ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
period	Σ	1..1	Period	Time of service that is being documented ele-1: All FHIR elements must have a @value or children
start	SΣC	1..1	dateTime	Starting time with inclusive boundary ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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 DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
meta
lastUpdated	S	0..1	instant	When the resource version last changed
security		0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required)
implicitRules		0..0
language		0..0
contained		0..0
masterIdentifier		0..0
identifier		0..0
status		1..1	code	current | superseded | entered-in-error Required Pattern: current
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
coding
system		0..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display		0..1	string	Representation defined by the system Required Pattern: Consult Note
category		0..0
subject	S	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
reference		0..1	string	Reference to Patient resource
display		0..1	string	External Name of Patient
date	S	0..1	instant	When this document reference was created
author	S	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
reference		0..1	string	Reference to Practitioner resource
display		0..1	string	External Name of Practitioner
content	S	1..*	BackboneElement	Document referenced
attachment	S	1..1	Attachment	Where to access the document
contentType	S	1..1	code	Mime type of the content, with charset etc.
data	S	1..1	base64Binary	Data inline, base64ed
format	S	1..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
context	S	1..1	BackboneElement	Clinical context of document
period		1..1	Period	Time of service that is being documented
start	S	1..1	dateTime	Starting time with inclusive boundary
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..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	Σ	0..*	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
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	Σ	0..*	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	Σ	0..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..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	1..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	1..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	1..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	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..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	Conformance	ValueSet / Code	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
DocumentReference.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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 DocumentReference

Summary

Mandatory: 11 elements
Must-Support: 14 elements
Prohibited: 6 elements

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources dom-3: 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 dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated dom-5: If a resource is contained in another resource, it SHALL NOT have a security label dom-6: A resource should have narrative for robust management
meta	Σ	0..1	Meta	Metadata about the resource ele-1: All FHIR elements must have a @value or children
lastUpdated	SΣ	0..1	instant	When the resource version last changed ele-1: All FHIR elements must have a @value or children
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required) ele-1: All FHIR elements must have a @value or children
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children Required Pattern: current
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. ele-1: All FHIR elements must have a @value or children
subject	SΣ	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
reference	ΣC	0..1	string	Reference to Patient resource ele-1: All FHIR elements must have a @value or children
display	Σ	0..1	string	External Name of Patient ele-1: All FHIR elements must have a @value or children
date	SΣ	0..1	instant	When this document reference was created ele-1: All FHIR elements must have a @value or children
author	SΣ	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document ele-1: All FHIR elements must have a @value or children
reference	ΣC	0..1	string	Reference to Practitioner resource ele-1: All FHIR elements must have a @value or children
display	Σ	0..1	string	External Name of Practitioner ele-1: All FHIR elements must have a @value or children
content	SΣ	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
attachment	SΣ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
contentType	SΣ	1..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. ele-1: All FHIR elements must have a @value or children Example General: text/plain; charset=UTF-8, image/png
data	S	1..1	base64Binary	Data inline, base64ed ele-1: All FHIR elements must have a @value or children
format	SΣ	1..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required) ele-1: All FHIR elements must have a @value or children
system	SΣ	1..1	uri	Identity of the terminology system ele-1: All FHIR elements must have a @value or children
code	SΣ	1..1	code	Symbol in syntax defined by the system ele-1: All FHIR elements must have a @value or children
context	SΣ	1..1	BackboneElement	Clinical context of document ele-1: All FHIR elements must have a @value or children
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
period	Σ	1..1	Period	Time of service that is being documented ele-1: All FHIR elements must have a @value or children
start	SΣC	1..1	dateTime	Starting time with inclusive boundary ele-1: All FHIR elements must have a @value or children
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG

Constraints

Id	Grade	Path(s)	Details	Requirements
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 DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
meta
lastUpdated	S	0..1	instant	When the resource version last changed
security		0..*	Coding	Security Labels applied to this resource Binding: Definition of Confidentiality Value Set (required)
implicitRules		0..0
language		0..0
contained		0..0
masterIdentifier		0..0
identifier		0..0
status		1..1	code	current | superseded | entered-in-error Required Pattern: current
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible)
coding
system		0..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
code		0..1	code	Symbol in syntax defined by the system Required Pattern: 11488-4
display		0..1	string	Representation defined by the system Required Pattern: Consult Note
category		0..0
subject	S	1..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
reference		0..1	string	Reference to Patient resource
display		0..1	string	External Name of Patient
date	S	0..1	instant	When this document reference was created
author	S	1..1	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
reference		0..1	string	Reference to Practitioner resource
display		0..1	string	External Name of Practitioner
content	S	1..*	BackboneElement	Document referenced
attachment	S	1..1	Attachment	Where to access the document
contentType	S	1..1	code	Mime type of the content, with charset etc.
data	S	1..1	base64Binary	Data inline, base64ed
format	S	1..1	Coding	Format/content rules for the document Binding: Consultation Note Content Format Value Set (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
context	S	1..1	BackboneElement	Clinical context of document
period		1..1	Period	Time of service that is being documented
start	S	1..1	dateTime	Starting time with inclusive boundary
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..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	Σ	0..*	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
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	Σ	0..*	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	Σ	0..1	uri	Identity of the terminology system Required Pattern: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	Σ	0..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	1..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	1..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	1..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	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..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	Conformance	ValueSet / Code	URI
DocumentReference.meta.security	required	ConfidentialityVS https://alexapi.medtechglobal.com.au/fhir/ValueSet/confidentiality from this IG
DocumentReference.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard
DocumentReference.status	required	Pattern: current http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
DocumentReference.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types from the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	ConsultationNoteContentFormat (a valid code from Consultation Note Content Format CodeSystem) https://alexapi.medtechglobal.com.au/fhir/ValueSet/consultation-note-content-format from this IG
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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 DocumentReference

Summary

Mandatory: 11 elements
Must-Support: 14 elements
Prohibited: 6 elements

Other representations of profile: CSV, Excel, Schematron