North West Genomics Testing Workflow (GTW)
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DRAFT Implementation Guide

This is for collaboration and discussion purposes and is subject to change.

North West Genomics Testing Workflow (GTW) - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: DocumentReference

Official URL: https://hl7.mft.nhs.uk/StructureDefinition/DocumentReference Version: 0.0.1
Draft as of 2025-02-22 Computable Name: DocumentReference

Based on UK Definitions from IHE Europe Metadata for exchange medical documents and images

Reference Standards

XDS DocumentEntry and MHD (FHIR) DocumentReference Mapping

For HL7 v2 MDM T02, see HL7 v2 MDM T02 Mapping

Note: links to HL7 FHIR Practitioner has removed several IHE XDS Document Entry fields, and just retained identifier and name. It is expected these values would be available via the NHS England Healthcare Worker API which may conform to IHE Mobile Care Services Discovery (mCSD) interface contracts.

IHE XDS Document Entry IHE MHD FHIR DocumentReference Use Description NHS Data Dictionary
uniqueId masterIdentifier Primary Query The globally unique identifier assigned by the document creator to this document. This unique identifier may be used in the body of other documents to reference this document. The structure and format of this Id is consistent with the document content Interoperability Specification, in particular with the formatCode attribute. Has a single value.  
entryUUID identifier Technical This globally unique identifier is primarily intended foruse as a document registry management identifier. It is not meant to be an external reference (outside of the Document Registry) for documents (e.g., in links within other documents)  
availabilityStatus status Primary Query    
type type Secondary Filtering The code specifying the precise type of document from the user perspective (e.g. Pulmonary History and Physical, Discharge Summary, Ultrasound Report).  
class category Primary Query The code specifying the high-level use classification of the document type (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow). The code specifying the particular kind of document. Shall have a single value. Coded with a coarse level of granularity.  
patientId subject Primary Query The patientId represents the subject of care of the document. It contains the Health ID with its two parts: Authority Domain Id (OID/System Uri enforced by the Registry) An Id in the above domain issued by the PDQ Supplier Actor (NHS England PAS) NHS Number
author author Secondary Filtering The humans and/or machines that authored the document. Organisation Code
CONSULTANT + GMP Code
creationTime content.attachment.date Secondary Filtering    
title content.attachment.title Secondary Filtering Represents the title of the document  
comments description Secondary Filtering Comments associated with the Document.  
confidentialityCode securityLabel Primary Query The code specifying the level of confidentiality of the document. Has one or more values.  
eventCodeList context.event Primary Query This list of codes represents the main clinical “key words” for queries specific to certain document content (e.g. test panel code for laboratory results).The value chosen shall not conflict with the values selected in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This value list may have zero or more values.  
serviceStartTime and serviceStopTime context.period Primary Query Represents the start and stop time the service being documented took place (clinically significant, but not necessarily when the document was produced or approved).  
practiceSettingCode context.practiceSetting Primary Query This code represents the type of organizational setting of the clinical encounter during which the documented act occurred. The code specifying the clinical specialty where the act that resulted in the document was performed (e.g., Intensive care, Laboratory, Radiology). Coarse level of granularity. Has a single value Main Specialty Code
healthcareFacilityTypeCode context.facilityType Primary Query This code represents the type of organization where the clinical encounter during which the documented act occurred. The value chosen in the value set needs to avoid conflict with the value used in the typeCode, as such a conflict would create an ambiguous situation. Has a single value. ACTIVITY LOCATION TYPE CODE
sourcePatientInfo and sourcePatientId context.sourcePatientInfo   The sourcePatientId represents the subject of care medical record Identifier (e.g., Patient Id) in the local patientIdentifier Domain of the Document Source. If used, it contains two parts:Authority Domain Id (System Uri/OID) and an Id in the local domain (e.g., Patient Id). It is only intended as an audit/checking mechanism and has occasional use for Document Consumer Actors. Medical Record Number
referenceIdList context.related Primary Query This list contains zero or more Identifiers. These Identifiers may be internal or external identifiers, E.g., Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDW Workflow, Instance Identifiers, etc. Accession Number
mimeType content.attachment.contentType Technical MIME type of the document in the Repository. Shall have a single value  
URI content.attachment.uri Technical The URI for the document  
languageCode content.attachment.language   Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066. Has a single value.  
formatCode content.format Technical Code globally uniquely specifying the format of the document. Along with the typeCode, it provides sufficient information to allow any potential Document Consumer to know if it will be able to process/display the document by identifying an encoding, structure and template  
hash content.attachment.hash Technical Hash key of the document itself. This value is computed by the Document Repository and used by the Document Registry for detecting tampering or the improper resubmission of documents .Has a single value  
size content.attachment.size Technical Size in bytes of the byte stream of the document  
legalAuthenticator authenticator   Represents a participant within an authorInstitution who has legally authenticated or attested the document. Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator. This attribute may be absent if not applicable. If present, shall have a single value  
Associations relatesTo   Relationships to other documents  
Associations type relatesTo.code      
Associations reference relatesTo.target      
objectType     The type of DocumentEntry (e.g. On-Demand DocumentEntry)  

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from UKCoreDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference A reference to a document
... identifier 1..* CorrelationIdentifier Other identifiers for the document
... type 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
... category 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
... subject 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumber Logical reference, when literal reference is not known
... author 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
.... identifier 0..1 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
... content
.... attachment 1..1 NWAttachment Where to access the document
... context
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
..... identifier 0..1 MedicalRecordNumber Logical reference, when literal reference is not known
.... Slices for related 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
..... related:fillerOrderNumber S 0..1 Reference(ServiceRequest) Related identifiers or resources
...... type S 1..1 uri Type the reference refers to (e.g. "Patient")
Required Pattern: ServiceRequest
...... identifier 1..1 FillerOrderNumber Logical reference, when literal reference is not known
..... related:accessionNumber S 0..1 Reference(ServiceRequest) Related identifiers or resources
...... type S 1..1 uri Type the reference refers to (e.g. "Patient")
Required Pattern: ServiceRequest
...... identifier 1..1 AccessionNumber Logical reference, when literal reference is not known

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference A reference to a document
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
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-6: A resource should have narrative for robust management
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
... 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
... modifierExtension ?!N 0..* Extension Extensions that cannot be ignored
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
... identifier SΣ 1..* CorrelationIdentifier Other identifiers for the document
ele-1: All FHIR elements must have a @value or children
... status ?!SΣ 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
... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
ele-1: All FHIR elements must have a @value or children
... category SΣ 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
ele-1: All FHIR elements must have a @value or children
... subject SΣC 1..1 Reference(Patient) Who/what is the subject of the document
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
.... identifier Σ 0..1 NHSNumber Logical reference, when literal reference is not known
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 SΣC 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
.... identifier Σ 0..1 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
... description SΣ 0..1 string Human-readable description
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 ΣC 1..1 NWAttachment Where to access the document
ele-1: All FHIR elements must have a @value or children
att-1: If the Attachment has data, it SHALL have a contentType
... context Σ 0..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
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


ele-1: All FHIR elements must have a @value or children
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
ele-1: All FHIR elements must have a @value or children
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
ele-1: All FHIR elements must have a @value or children
.... sourcePatientInfo C 0..1 Reference(Patient) Patient demographics from source
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
..... identifier Σ 0..1 MedicalRecordNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
.... Slices for related C 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
..... related:fillerOrderNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
...... type SΣ 1..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).


ele-1: All FHIR elements must have a @value or children
Required Pattern: ServiceRequest
...... identifier Σ 1..1 FillerOrderNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
..... related:accessionNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
...... type SΣ 1..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).


ele-1: All FHIR elements must have a @value or children
Required Pattern: ServiceRequest
...... identifier Σ 1..1 AccessionNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG
DocumentReference.context.related:fillerOrderNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:accessionNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!N 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 1..* CorrelationIdentifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
... category SΣ 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
... subject SΣC 1..1 Reference(Patient) Who/what is the subject of the document
ref-1: SHALL have a contained resource if a local reference is provided
.... 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 Literal reference, Relative, internal or absolute URL
.... 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 NHSNumber Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... date SΣ 0..1 instant When this document reference was created
... author SΣC 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
ref-1: SHALL have a contained resource if a local reference is provided
.... 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 Literal reference, Relative, internal or absolute URL
.... 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 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... authenticator C 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
ref-1: SHALL have a contained resource if a local reference is provided
... custodian C 0..1 Reference(Organization) Organization which maintains the document
ref-1: SHALL have a contained resource if a local reference is provided
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... 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 ΣC 1..1 Reference(DocumentReference) Target of the relationship
ref-1: SHALL have a contained resource if a local reference is provided
... description SΣ 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 N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment ΣC 1..1 NWAttachment Where to access the document
att-1: If the Attachment has data, it SHALL have a contentType
.... 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 N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter C 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
ref-1: SHALL have a contained resource if a local reference is provided
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period ΣC 0..1 Period Time of service that is being documented
per-1: If present, start SHALL have a lower value than end
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
.... sourcePatientInfo C 0..1 Reference(Patient) Patient demographics from source
ref-1: SHALL have a contained resource if a local reference is provided
..... 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 Literal reference, Relative, internal or absolute URL
..... 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 MedicalRecordNumber Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... Slices for related C 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
ref-1: SHALL have a contained resource if a local reference is provided
..... related:fillerOrderNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ref-1: SHALL have a contained resource if a local reference is provided
...... 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 Literal reference, Relative, internal or absolute URL
...... type SΣ 1..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).


Required Pattern: ServiceRequest
...... identifier Σ 1..1 FillerOrderNumber Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... related:accessionNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ref-1: SHALL have a contained resource if a local reference is provided
...... 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 Literal reference, Relative, internal or absolute URL
...... type SΣ 1..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).


Required Pattern: ServiceRequest
...... identifier Σ 1..1 AccessionNumber Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DocumentReference.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG
DocumentReference.context.sourcePatientInfo.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:fillerOrderNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:accessionNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Differential View

This structure is derived from UKCoreDocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference A reference to a document
... identifier 1..* CorrelationIdentifier Other identifiers for the document
... type 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
... category 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
... subject 1..1 Reference(Patient) Who/what is the subject of the document
.... identifier 0..1 NHSNumber Logical reference, when literal reference is not known
... author 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
.... identifier 0..1 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
... content
.... attachment 1..1 NWAttachment Where to access the document
... context
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
..... identifier 0..1 MedicalRecordNumber Logical reference, when literal reference is not known
.... Slices for related 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
..... related:fillerOrderNumber S 0..1 Reference(ServiceRequest) Related identifiers or resources
...... type S 1..1 uri Type the reference refers to (e.g. "Patient")
Required Pattern: ServiceRequest
...... identifier 1..1 FillerOrderNumber Logical reference, when literal reference is not known
..... related:accessionNumber S 0..1 Reference(ServiceRequest) Related identifiers or resources
...... type S 1..1 uri Type the reference refers to (e.g. "Patient")
Required Pattern: ServiceRequest
...... identifier 1..1 AccessionNumber Logical reference, when literal reference is not known

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference A reference to a document
dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
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-6: A resource should have narrative for robust management
dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
... 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
... modifierExtension ?!N 0..* Extension Extensions that cannot be ignored
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
... identifier SΣ 1..* CorrelationIdentifier Other identifiers for the document
ele-1: All FHIR elements must have a @value or children
... status ?!SΣ 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
... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
ele-1: All FHIR elements must have a @value or children
... category SΣ 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
ele-1: All FHIR elements must have a @value or children
... subject SΣC 1..1 Reference(Patient) Who/what is the subject of the document
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
.... identifier Σ 0..1 NHSNumber Logical reference, when literal reference is not known
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 SΣC 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
.... identifier Σ 0..1 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
... description SΣ 0..1 string Human-readable description
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 ΣC 1..1 NWAttachment Where to access the document
ele-1: All FHIR elements must have a @value or children
att-1: If the Attachment has data, it SHALL have a contentType
... context Σ 0..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
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


ele-1: All FHIR elements must have a @value or children
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
ele-1: All FHIR elements must have a @value or children
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
ele-1: All FHIR elements must have a @value or children
.... sourcePatientInfo C 0..1 Reference(Patient) Patient demographics from source
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
..... identifier Σ 0..1 MedicalRecordNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
.... Slices for related C 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
..... related:fillerOrderNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
...... type SΣ 1..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).


ele-1: All FHIR elements must have a @value or children
Required Pattern: ServiceRequest
...... identifier Σ 1..1 FillerOrderNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children
..... related:accessionNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ele-1: All FHIR elements must have a @value or children
ref-1: SHALL have a contained resource if a local reference is provided
...... type SΣ 1..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).


ele-1: All FHIR elements must have a @value or children
Required Pattern: ServiceRequest
...... identifier Σ 1..1 AccessionNumber Logical reference, when literal reference is not known
ele-1: All FHIR elements must have a @value or children

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG
DocumentReference.context.related:fillerOrderNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:accessionNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* UKCoreDocumentReference 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 BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
... modifierExtension ?!N 0..* Extension Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 1..* CorrelationIdentifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required): The status of the document reference.

... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: Document Entry Type (required)
... category SΣ 0..* CodeableConcept Categorization of document
Binding: Document Entry Class (required)
... subject SΣC 1..1 Reference(Patient) Who/what is the subject of the document
ref-1: SHALL have a contained resource if a local reference is provided
.... 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 Literal reference, Relative, internal or absolute URL
.... 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 NHSNumber Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... date SΣ 0..1 instant When this document reference was created
... author SΣC 0..* Reference(Organization | Practitioner | PractitionerRole) Who and/or what authored the document
ref-1: SHALL have a contained resource if a local reference is provided
.... 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 Literal reference, Relative, internal or absolute URL
.... 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 EnglandPractitionerIdentifier, OrganisationCode Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... authenticator C 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
ref-1: SHALL have a contained resource if a local reference is provided
... custodian C 0..1 Reference(Organization) Organization which maintains the document
ref-1: SHALL have a contained resource if a local reference is provided
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... 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 ΣC 1..1 Reference(DocumentReference) Target of the relationship
ref-1: SHALL have a contained resource if a local reference is provided
... description SΣ 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 N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment ΣC 1..1 NWAttachment Where to access the document
att-1: If the Attachment has data, it SHALL have a contentType
.... 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 N 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter C 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
ref-1: SHALL have a contained resource if a local reference is provided
.... event 0..* CodeableConcept The procedure or test code associated with the Accession Number (e.g. NICIP, Genomic Test Directory, etc.)
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period ΣC 0..1 Period Time of service that is being documented
per-1: If present, start SHALL have a lower value than end
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type (required)
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Specialty (required)
.... sourcePatientInfo C 0..1 Reference(Patient) Patient demographics from source
ref-1: SHALL have a contained resource if a local reference is provided
..... 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 Literal reference, Relative, internal or absolute URL
..... 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 MedicalRecordNumber Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... Slices for related C 0..* Reference(Resource) Related identifiers or resources
Slice: Unordered, Open by pattern:identifier.type
ref-1: SHALL have a contained resource if a local reference is provided
..... related:fillerOrderNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ref-1: SHALL have a contained resource if a local reference is provided
...... 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 Literal reference, Relative, internal or absolute URL
...... type SΣ 1..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).


Required Pattern: ServiceRequest
...... identifier Σ 1..1 FillerOrderNumber Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource
..... related:accessionNumber SC 0..1 Reference(ServiceRequest) Related identifiers or resources
ref-1: SHALL have a contained resource if a local reference is provided
...... 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 Literal reference, Relative, internal or absolute URL
...... type SΣ 1..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).


Required Pattern: ServiceRequest
...... identifier Σ 1..1 AccessionNumber Logical reference, when literal reference is not known
...... display Σ 0..1 string Text alternative for the resource

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / CodeURI
DocumentReference.languagepreferredCommonLanguages
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredDocumentEntryType
https://hl7.mft.nhs.uk/ValueSet/document-entry-type
from this IG
DocumentReference.categoryrequiredDocumentEntryClass
https://hl7.mft.nhs.uk/ValueSet/document-entry-class
from this IG
DocumentReference.subject.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.author.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
http://hl7.org/fhir/ValueSet/formatcodes
from the FHIR Standard
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTyperequiredFacilityType
https://hl7.mft.nhs.uk/ValueSet/facility-type
from this IG
DocumentReference.context.practiceSettingrequiredSpecialty
https://hl7.mft.nhs.uk/ValueSet/specialty
from this IG
DocumentReference.context.sourcePatientInfo.typeextensibleResourceType
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:fillerOrderNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard
DocumentReference.context.related:accessionNumber.typeextensiblePattern: ServiceRequest
http://hl7.org/fhir/ValueSet/resource-types
from the FHIR Standard

 

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