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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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
masterIdentifier	Σ	1..1	Identifier	Master Version Specific Identifier ele-1: All FHIR elements must have a @value or children
identifier	Σ	0..*	Identifier	Other document identifiers ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	Status of this document reference. Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children Required Pattern: current
docStatus	Σ	0..1	code	Composition status Binding: CompositionStatus (required): Status of the underlying document. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required) ele-1: All FHIR elements must have a @value or children
Slices for category	Σ	0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
category:studyType	Σ	0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient: Minimal)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
date	Σ	1..1	instant	When this document reference was created ele-1: All FHIR elements must have a @value or children
description	Σ	1..1	string	Human-readable description ele-1: All FHIR elements must have a @value or children
content	ΣC	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children docref-no-data: attachment.data shall not be present if the document is not a PDF
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	Σ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
contentType	Σ	0..1	code	Type of data (e.g. PDF) 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		0..1	base64Binary	Used only for PDF ele-1: All FHIR elements must have a @value or children
url	Σ	0..1	url	Where the doc can be get ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/logo-small.png
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
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	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType
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

Constraints

Id	Grade	Path(s)	Details	Requirements
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()
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()

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality
masterIdentifier		1..1	Identifier	Master Version Specific Identifier
identifier		0..*	Identifier	Other document identifiers
status		1..1	code	Status of this document reference. Required Pattern: current
docStatus		0..1	code	Composition status
type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required)
Slices for category		0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this
category:studyType		0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required)
subject		1..1	Reference(Patient: Minimal)	Who/what is the subject of the document
date		1..1	instant	When this document reference was created
description		1..1	string	Human-readable description
content	C	1..*	BackboneElement	Document referenced docref-no-data: attachment.data shall not be present if the document is not a PDF
attachment
contentType		0..1	code	Type of data (e.g. PDF)
data		0..1	base64Binary	Used only for PDF
url		0..1	url	Where the doc can be get
context
period		0..1	Period	Time the service documented
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType

Constraints

Id	Grade	Path(s)	Details	Requirements
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()

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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	1..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other document identifiers
status	?!Σ	1..1	code	Status of this document reference. Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
docStatus	Σ	0..1	code	Composition status Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required)
Slices for category	Σ	0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:studyType	Σ	0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required)
subject	Σ	1..1	Reference(Patient: Minimal)	Who/what is the subject of the document
date	Σ	1..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
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	1..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	ΣC	1..*	BackboneElement	Document referenced docref-no-data: attachment.data shall not be present if the document is not a PDF
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	Σ	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	Σ	0..1	code	Type of data (e.g. PDF) 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		0..1	base64Binary	Used only for PDF
url	Σ	0..1	url	Where the doc can be get 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	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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	0..1	Period	Time the service documented
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.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
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	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType
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	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
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
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()
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()

Summary

Mandatory: 5 elements

Structures

This structure refers to these other structures:

• Patient: Minimal (http://myhealth.eu/fhir/ncp-api/StructureDefinition/Patient-minimal-myhealtheu)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.category

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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created ele-1: All FHIR elements must have a @value or children
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality ele-1: All FHIR elements must have a @value or children ext-1: Must have either extensions or value[x], not both
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
masterIdentifier	Σ	1..1	Identifier	Master Version Specific Identifier ele-1: All FHIR elements must have a @value or children
identifier	Σ	0..*	Identifier	Other document identifiers ele-1: All FHIR elements must have a @value or children
status	?!Σ	1..1	code	Status of this document reference. Binding: DocumentReferenceStatus (required): The status of the document reference. ele-1: All FHIR elements must have a @value or children Required Pattern: current
docStatus	Σ	0..1	code	Composition status Binding: CompositionStatus (required): Status of the underlying document. ele-1: All FHIR elements must have a @value or children
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required) ele-1: All FHIR elements must have a @value or children
Slices for category	Σ	0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. ele-1: All FHIR elements must have a @value or children
category:studyType	Σ	0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required) ele-1: All FHIR elements must have a @value or children
subject	Σ	1..1	Reference(Patient: Minimal)	Who/what is the subject of the document ele-1: All FHIR elements must have a @value or children
date	Σ	1..1	instant	When this document reference was created ele-1: All FHIR elements must have a @value or children
description	Σ	1..1	string	Human-readable description ele-1: All FHIR elements must have a @value or children
content	ΣC	1..*	BackboneElement	Document referenced ele-1: All FHIR elements must have a @value or children docref-no-data: attachment.data shall not be present if the document is not a PDF
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	Σ	1..1	Attachment	Where to access the document ele-1: All FHIR elements must have a @value or children
contentType	Σ	0..1	code	Type of data (e.g. PDF) 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		0..1	base64Binary	Used only for PDF ele-1: All FHIR elements must have a @value or children
url	Σ	0..1	url	Where the doc can be get ele-1: All FHIR elements must have a @value or children Example General: http://www.acme.com/logo-small.png
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
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	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType
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

Constraints

Id	Grade	Path(s)	Details	Requirements
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()
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()

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality
masterIdentifier		1..1	Identifier	Master Version Specific Identifier
identifier		0..*	Identifier	Other document identifiers
status		1..1	code	Status of this document reference. Required Pattern: current
docStatus		0..1	code	Composition status
type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required)
Slices for category		0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this
category:studyType		0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required)
subject		1..1	Reference(Patient: Minimal)	Who/what is the subject of the document
date		1..1	instant	When this document reference was created
description		1..1	string	Human-readable description
content	C	1..*	BackboneElement	Document referenced docref-no-data: attachment.data shall not be present if the document is not a PDF
attachment
contentType		0..1	code	Type of data (e.g. PDF)
data		0..1	base64Binary	Used only for PDF
url		0..1	url	Where the doc can be get
context
period		0..1	Period	Time the service documented
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType

Constraints

Id	Grade	Path(s)	Details	Requirements
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()

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
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:modality-r5		0..*	CodeableConcept	Optional Extensions Element URL: http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	1..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other document identifiers
status	?!Σ	1..1	code	Status of this document reference. Binding: DocumentReferenceStatus (required): The status of the document reference. Required Pattern: current
docStatus	Σ	0..1	code	Composition status Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: eHDSI Document Types (required)
Slices for category	Σ	0..*	CodeableConcept	Report Category Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:studyType	Σ	0..*	CodeableConcept	The way of grouping of the test results into clinically meaningful domains (e.g. hematology study, microbiology study, etc.) Binding: eHDSI Laboratory Study Types (required)
subject	Σ	1..1	Reference(Patient: Minimal)	Who/what is the subject of the document
date	Σ	1..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
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	1..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	ΣC	1..*	BackboneElement	Document referenced docref-no-data: attachment.data shall not be present if the document is not a PDF
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	Σ	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	Σ	0..1	code	Type of data (e.g. PDF) 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		0..1	base64Binary	Used only for PDF
url	Σ	0..1	url	Where the doc can be get 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	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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	0..1	Period	Time the service documented
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.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages from the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
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	required	EHDSIDocumentTypes http://myhealth.eu/fhir/ncp-api/ValueSet/eHDSIDocumentTypes from this IG
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard
DocumentReference.category:studyType	required	EHDSILabStudyType http://terminology.ehdsi.eu/ValueSet/eHDSILabStudyType
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	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
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
docref-no-data	error	DocumentReference.content	attachment.data shall not be present if the document is not a PDF : attachment.where(contentType != 'application/pdf').data.empty()
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()

Summary

Mandatory: 5 elements

Structures

This structure refers to these other structures:

• Patient: Minimal (http://myhealth.eu/fhir/ncp-api/StructureDefinition/Patient-minimal-myhealtheu)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/5.0/StructureDefinition/extension-DocumentReference.modality

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.category