This page is part of the Médicosocial - Suivi Décisions Orientation (v4.0.2-ballot: Release) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 4.0.4. For a full list of available versions, see the Directory of published versions

• Content
• Detailed Descriptions
• Mappings
• Examples
• XML
• JSON
• TTL

Resource Profile: SDODocumentReference

Profil pour définir le dossier SDO

Usage:

• Derived from this Resource Profile: ESMSDocumentReference
• Examples for this Resource Profile: DocumentReference/id-exemple-sdo-document-reference-np and DocumentReference/id-exemple-sdo-document-reference

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			DocumentReference
identifier		1..*	Identifier	Other identifiers for the document
content		1..1	BackboneElement	Document referenced
Documentation for this format

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
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	1..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
content	Σ	1..1	BackboneElement	Document referenced
modifierExtension	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣCN	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus

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.modifierExtension, DocumentReference.content.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	ΣN	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	N	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	ΣN	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	1..*	Identifier	Other identifiers for the document
status	?!Σ	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	ΣN	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	ΣN	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	ΣCN	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	ΣCN	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator	CN	0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian	CN	0..1	Reference(Organization)	Organization which maintains the document
relatesTo	ΣN	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	?!ΣN	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	ΣCN	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	ΣN	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..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	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣCN	1..1	Attachment	Where to access the document
format	ΣN	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	ΣN	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	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	CN	0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event	N	0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	ΣCN	0..1	Period	Time of service that is being documented
facilityType	N	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	N	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	CN	0..1	Reference(Patient)	Patient demographics from source
related	CN	0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

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()
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.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, 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.authenticator, DocumentReference.custodian, 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: 1 element

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference			DocumentReference
identifier		1..*	Identifier	Other identifiers for the document
content		1..1	BackboneElement	Document referenced
Documentation for this format

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
modifierExtension	?!N	0..*	Extension	Extensions that cannot be ignored Slice: Unordered, Open by value:url
identifier	Σ	1..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
content	Σ	1..1	BackboneElement	Document referenced
modifierExtension	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣCN	1..1	Attachment	Where to access the document
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus

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.modifierExtension, DocumentReference.content.modifierExtension	Must have either extensions or value[x], not both : extension.exists() != value.exists()

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	ΣN	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	N	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	ΣN	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	1..*	Identifier	Other identifiers for the document
status	?!Σ	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	ΣN	0..1	CodeableConcept	Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
category	ΣN	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	ΣCN	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
date	Σ	0..1	instant	When this document reference was created
author	ΣCN	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator	CN	0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian	CN	0..1	Reference(Organization)	Organization which maintains the document
relatesTo	ΣN	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	?!ΣN	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	ΣCN	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	ΣN	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..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	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	ΣCN	1..1	Attachment	Where to access the document
format	ΣN	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	ΣN	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	?!ΣN	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	CN	0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
event	N	0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	ΣCN	0..1	Period	Time of service that is being documented
facilityType	N	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	N	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	CN	0..1	Reference(Patient)	Patient demographics from source
related	CN	0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	preferred	DocumentTypeValueSet
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

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()
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.modifierExtension, DocumentReference.relatesTo.extension, DocumentReference.relatesTo.modifierExtension, DocumentReference.content.extension, DocumentReference.content.modifierExtension, 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.authenticator, DocumentReference.custodian, 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: 1 element

Other representations of profile: CSV, Excel, Schematron