This page is part of the Guide d'implémentation cahier de liaison (v3.0.0-ballot: Release) based on FHIR (HL7® FHIR® Standard) R4. . For a full list of available versions, see the Directory of published versions

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Resource Profile: DocumentReference Cahier de Liaison

Profil de la ressource DocumentReference pour le cahier de liaison. Il regroupe les informations relatives à la note.

Usage:

• Use this Resource Profile: Bundle de création d'une note, Bundle de mise à jour d'une note and Bundle résultat recherche notes

Formal Views of Profile Content

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

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
Slices for extension				Content/Rules for all slices
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
masterIdentifier	S	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
status	S	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts
docStatus		0..0
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
subject	S	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document
date	S	0..1	instant	When this document reference was created
author	S	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel.
authenticator		0..0
custodian		0..0
relatesTo		0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
description	S	0..1	string	Human-readable description
securityLabel	S	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	S	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
attachment		1..1	Attachment	Where to access the document
contentType	S	0..1	code	Mime type of the content, with charset etc.
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
title	S	0..1	string	Label to display in place of the data
creation	S	0..1	dateTime	Date attachment was first created
context	S	0..1	BackboneElement	Clinical context of document
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.securityLabel	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
masterIdentifier	SΣ	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
status	?!SΣ	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
subject	SΣC	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document ref-1: SHALL have a contained resource if a local reference is provided
date	SΣ	0..1	instant	When this document reference was created
author	SΣC	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel. ref-1: SHALL have a contained resource if a local reference is provided
relatesTo	Σ	0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
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	SΣ	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	SΣ	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣC	1..1	Attachment	Where to access the document att-1: If the Attachment has data, it SHALL have a contentType
contentType	SΣ	0..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
title	SΣ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	0..1	dateTime	Date attachment was first created
context	SΣ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS
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
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	DocumentReference.extension:isEmergency, DocumentReference.modifierExtension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.modifierExtension, DocumentReference.context.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ref-1	error	DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

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	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
masterIdentifier	SΣ	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!SΣ	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣC	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document ref-1: SHALL have a contained resource if a local reference is provided
date	SΣ	0..1	instant	When this document reference was created
author	SΣC	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel. ref-1: SHALL have a contained resource if a local reference is provided
relatesTo	Σ	0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
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	SΣ	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	SΣ	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
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	Attachment	Where to access the document att-1: If the Attachment has data, it SHALL have a contentType
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
contentType	SΣ	0..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	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	SΣ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	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	SΣ	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	Main clinical acts documented 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: 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	C	0..1	Reference(Patient)	Patient demographics from source ref-1: SHALL have a contained resource if a local reference is provided
related	C	0..*	Reference(Resource)	Related identifiers or resources ref-1: SHALL have a contained resource if a local reference is provided
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes 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	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	DocumentReference.extension, DocumentReference.extension:isEmergency, DocumentReference.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.content.attachment.extension, DocumentReference.context.extension, DocumentReference.context.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
per-1	error	DocumentReference.context.period	If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1	error	DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target, DocumentReference.context.encounter, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 16 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

• FR Core Patient Profile (https://hl7.fr/ig/fhir/core/StructureDefinition/fr-core-patient)
• FR Core Related Person Profile (https://hl7.fr/ig/fhir/core/StructureDefinition/fr-core-related-person)
• AS Practitioner Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-practitioner)
• AS PractitionerRole Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-practitionerrole)
• AS Organization Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-organization)

Extensions

This structure refers to these extensions:

• https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
Slices for extension				Content/Rules for all slices
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
masterIdentifier	S	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
status	S	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts
docStatus		0..0
type	S	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
subject	S	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document
date	S	0..1	instant	When this document reference was created
author	S	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel.
authenticator		0..0
custodian		0..0
relatesTo		0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
description	S	0..1	string	Human-readable description
securityLabel	S	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	S	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
attachment		1..1	Attachment	Where to access the document
contentType	S	0..1	code	Mime type of the content, with charset etc.
data	S	0..1	base64Binary	Data inline, base64ed
url	S	0..1	url	Uri where the data can be found
title	S	0..1	string	Label to display in place of the data
creation	S	0..1	dateTime	Date attachment was first created
context	S	0..1	BackboneElement	Clinical context of document
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.securityLabel	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension				Content/Rules for all slices
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
masterIdentifier	SΣ	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
status	?!SΣ	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
subject	SΣC	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document ref-1: SHALL have a contained resource if a local reference is provided
date	SΣ	0..1	instant	When this document reference was created
author	SΣC	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel. ref-1: SHALL have a contained resource if a local reference is provided
relatesTo	Σ	0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
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	SΣ	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	SΣ	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣC	1..1	Attachment	Where to access the document att-1: If the Attachment has data, it SHALL have a contentType
contentType	SΣ	0..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
title	SΣ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	0..1	dateTime	Date attachment was first created
context	SΣ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard
DocumentReference.securityLabel	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS
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
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	DocumentReference.extension:isEmergency, DocumentReference.modifierExtension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.modifierExtension, DocumentReference.context.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
ref-1	error	DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

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
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	N	0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
isEmergency	S	0..*	boolean	L’urgence de la note qui permettra d’identifier la façon avec laquelle elle devra être prise en compte URL: https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
masterIdentifier	SΣ	0..1	Identifier	Identifiant de la note attribué par le système initiateur à l’origine de la création de la note
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!SΣ	1..1	code	Le statut de la note. Les gestionnaires de cahiers de liaison ne supportant pas la suppression de notes peuvent proposer leur désactivation par mise à jour de leurs statuts Binding: DocumentReferenceStatus (required): The status of the document reference.
type	SΣ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: JDV_J23-TypeNoteCahierLiaison-CISIS (required)
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣC	1..1	Reference(FR Core Patient Profile)	Who/what is the subject of the document ref-1: SHALL have a contained resource if a local reference is provided
date	SΣ	0..1	instant	When this document reference was created
author	SΣC	1..*	Reference(Device | FR Core Related Person Profile | FR Core Patient Profile | AS Practitioner Profile | AS PractitionerRole Profile | AS Organization Profile)	Auteur de la note. Il est préférable de privilégier la situation d'exercice (PractitionerRole) dans le cas où l'auteur est un professionnel. ref-1: SHALL have a contained resource if a local reference is provided
relatesTo	Σ	0..*	BackboneElement	Cet élément peut être utilisé pour lier des notes entre elles (note en réponse à une autre par exemple). Pour ce faire le code « appends » doit être utilisé dans relatesTo.code et relatesTo.reference doit pointer vers la note mère.
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	SΣ	0..1	CodeableConcept	Statut de visibilité de la note Binding: JDV_J110-StatutVisibiliteDocument-CISIS (required)
content	SΣ	1..*	BackboneElement	Contenu de la note. Cet élément qui représente le contenu de la note est répétable. Pour une note avec du texte et une photo par exemple, deux instances de l’élément « content » peuvent être présentes : une pour représenter le texte et une pour représenter la photo.
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	Attachment	Where to access the document att-1: If the Attachment has data, it SHALL have a contentType
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
contentType	SΣ	0..1	code	Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	S	0..1	base64Binary	Data inline, base64ed
url	SΣ	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	SΣ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	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	SΣ	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	Main clinical acts documented 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: 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	C	0..1	Reference(Patient)	Patient demographics from source ref-1: SHALL have a contained resource if a local reference is provided
related	C	0..*	Reference(Resource)	Related identifiers or resources ref-1: SHALL have a contained resource if a local reference is provided
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	required	JDV_J23-TypeNoteCahierLiaison-CISIS https://mos.esante.gouv.fr/NOS/JDV_J23-TypeNoteCahierLiaison-CISIS/FHIR/JDV-J23-TypeNoteCahierLiaison-CISIS
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes 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	required	JDV_J110-StatutVisibiliteDocument-CISIS https://mos.esante.gouv.fr/NOS/JDV_J110-StatutVisibiliteDocument-CISIS/FHIR/JDV-J110-StatutVisibiliteDocument-CISIS
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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
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
att-1	error	DocumentReference.content.attachment	If the Attachment has data, it SHALL have a contentType : data.empty() or contentType.exists()
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	DocumentReference.extension, DocumentReference.extension:isEmergency, DocumentReference.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, DocumentReference.content.attachment.extension, DocumentReference.context.extension, DocumentReference.context.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()
per-1	error	DocumentReference.context.period	If present, start SHALL have a lower value than end : start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1	error	DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target, DocumentReference.context.encounter, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related	SHALL have a contained resource if a local reference is provided : reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 16 elements
Prohibited: 3 elements

Structures

This structure refers to these other structures:

• FR Core Patient Profile (https://hl7.fr/ig/fhir/core/StructureDefinition/fr-core-patient)
• FR Core Related Person Profile (https://hl7.fr/ig/fhir/core/StructureDefinition/fr-core-related-person)
• AS Practitioner Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-practitioner)
• AS PractitionerRole Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-practitionerrole)
• AS Organization Profile (https://interop.esante.gouv.fr/ig/fhir/annuaire/StructureDefinition/as-organization)

Extensions

This structure refers to these extensions:

• https://interop.esante.gouv.fr/ig/fhir/cdl/StructureDefinition/cdl-ext-is-emergency

Other representations of profile: CSV, Excel, Schematron