Radiology (Sandbox)
0.0.1-current - ci-build
Radiology (Sandbox)
0.0.1-current - ci-build
Requirement Specification
This is for collaboration and discussion purposes and is subject to change.
This is not an Implementation Guide
Radiology (Sandbox) - Local Development build (v0.0.1-current) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://fhir.nhs.uk/England/RAD/StructureDefinition/DocumentEntry | Version: 0.0.1-current | |||
| Draft as of 2024-10-24 | Computable Name: DocumentEntry | |||
Based on
At present this is not based on UK Core DocumentReference as this is analysis of enterprise entity models but will be at a later date.
This is based on both FHIR DocumentReference and IHE (Europe) Document Metadata (this contains references to NHS England terminology)
Entity Document Entry
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 CODE GENERAL MEDICAL PRACTITIONER PPD 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. | RADIOLOGICAL 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) |
Internal NHS England link to DocumentReference elaboration https://nhsd-confluence.digital.nhs.uk/display/CLP/Category+vs+Type#CategoryvsType-FHIRdefinitionofClass/Category
Links to other countries Document Metadata definitions:
A summary of the current definitions of DocumentCategory and DocumentType is shown below with examples based on Care Plans:
Relationships between Document Metadata Type and Category and Composition Types
The example are from
Relationships between Document Metadata Type and Category and Composition Types Imaging
See
NICIP in both native and SNOMED versions contains several thousand codes, this may not be suitable for general searches from non radiologists. Also, DICOM Categories may be suitable for searching (for non radiologists) but is not included in IHE Europe documentations, need to find out if this has been considered.
Note this probably requires a ConceptMap
Both IHE and HL7 refer to clinical specialty where the event took place. UK Core has taken a Service route using SNOMED CT codes.
TODO - This is referring to NHS Data Model and Dictionary - TREATMENT FUNCTION CODE and UKCoreCareSettingType
NHS England is probably creating a new CodeSystem on the Ontology Server
Note this probably requires a ConceptMap
In FHIR this would also be available via author.PractitionerRole.specialty
This is referring to MAIN SPECIALTY CODE and UKCorePracticeSettingCode
Note this appears to be a source of confusion as practiceSetting is being linked to treatment-function-codes elsewhere.
NHS England is probably creating a new CodeSystem on the Ontology Server
Note this probably requires a ConceptMap
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from ComprehensiveDocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |
  identifier |
1..* | Identifier | Other identifiers for the document | |
| type |
1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | |
| category |
1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | |
| subject |
||||
   identifier |
0..1 | NHSNumber | An identifier intended for computation | |
 author |
0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | |
| identifier |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |
| context |
||||
  Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type | |
  event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented | |
 event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented | |
| facilityType |
1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |
| practiceSetting |
1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |
| sourcePatientInfo |
||||
| identifier |
0..1 | MedicalRecordNumber | An identifier intended for computation | |
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |
| related:accessionNumber |
S | 1..1 | Reference(Radiology 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 | An identifier intended for computation | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | |
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | |
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | |
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | |
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |||||
 implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| masterIdentifier |
1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
| Slices for identifier |
SΣ | 1..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
| identifier:entryUUID |
0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | ||||
| category |
SΣ | 1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| identifier |
0..1 | NHSNumber | An identifier intended for computation | |||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | ||||
| identifier |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |||||
| relatesTo |
SΣC | 0..* | BackboneElement | Relationships to other documents iti-mhd-repl: a DocumetReference replacements needs to relate to a superseded DocumentReference | ||||
 modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| securityLabel |
SΣ | 1..* | 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 | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
Σ | 1..1 | Attachment | Where to access the document | ||||
| contentType |
Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| url |
Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
| context |
Σ | 1..1 | BackboneElement | Clinical context of document | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |||||
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | ||||
| practiceSetting |
S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | ||||
| sourcePatientInfo |
S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
| identifier |
0..1 | MedicalRecordNumber | An identifier intended for computation | |||||
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |||||
| related:accessionNumber |
S | 1..1 | Reference(Radiology ServiceRequest) | Related identifiers or resources | ||||
| 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 |
1..1 | AccessionNumber | An identifier intended for computation | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats | ||||
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | ||||
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | ||||
| DocumentReference.context.event:anatomicRegion | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:ImagingProcedure | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | ||||
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG | ||||
| DocumentReference.context.related:accessionNumber.type | extensible | Pattern: ServiceRequesthttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
 extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| masterIdentifier |
1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
| Slices for identifier |
SΣ | 1..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
| identifier:entryUUID |
0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | ||||
| category |
SΣ | 1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | 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 |
0..1 | NHSNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | 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 |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
SΣC | 0..* | BackboneElement | Relationships to other documents iti-mhd-repl: a DocumetReference replacements needs to relate to a superseded DocumentReference | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
SΣ | 1..* | 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 |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
Σ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| url |
Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
| context |
Σ | 1..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | |||||
| Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |||||
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| start |
ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
| end |
ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| facilityType |
S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | ||||
| practiceSetting |
S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | ||||
| sourcePatientInfo |
S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
| 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 |
0..1 | MedicalRecordNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |||||
| related:accessionNumber |
S | 1..1 | Reference(Radiology ServiceRequest) | Related identifiers or resources | ||||
| 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 |
1..1 | AccessionNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsfrom the FHIR Standard | ||||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats | ||||
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | ||||
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | ||||
| DocumentReference.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | ||||
| DocumentReference.context.event:anatomicRegion | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:ImagingProcedure | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | ||||
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG | ||||
| DocumentReference.context.sourcePatientInfo.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.context.related:accessionNumber.type | extensible | Pattern: ServiceRequesthttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
This structure is derived from ComprehensiveDocumentReference
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from ComprehensiveDocumentReference
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |
| identifier |
1..* | Identifier | Other identifiers for the document | |
| type |
1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | |
| category |
1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | |
| subject |
||||
| identifier |
0..1 | NHSNumber | An identifier intended for computation | |
| author |
0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | |
| identifier |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |
| context |
||||
| Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type | |
| event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented | |
| event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented | |
| facilityType |
1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | |
| practiceSetting |
1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | |
| sourcePatientInfo |
||||
| identifier |
0..1 | MedicalRecordNumber | An identifier intended for computation | |
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |
| related:accessionNumber |
S | 1..1 | Reference(Radiology 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 | An identifier intended for computation | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet | URI |
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | |
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | |
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | |
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | |
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |||||
| implicitRules |
?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
| masterIdentifier |
1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
| Slices for identifier |
SΣ | 1..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
| identifier:entryUUID |
0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | ||||
| category |
SΣ | 1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| identifier |
0..1 | NHSNumber | An identifier intended for computation | |||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | ||||
| identifier |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |||||
| relatesTo |
SΣC | 0..* | BackboneElement | Relationships to other documents iti-mhd-repl: a DocumetReference replacements needs to relate to a superseded DocumentReference | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| securityLabel |
SΣ | 1..* | 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 | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
Σ | 1..1 | Attachment | Where to access the document | ||||
| contentType |
Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| url |
Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
| context |
Σ | 1..1 | BackboneElement | Clinical context of document | ||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |||||
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| facilityType |
S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | ||||
| practiceSetting |
S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | ||||
| sourcePatientInfo |
S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
| identifier |
0..1 | MedicalRecordNumber | An identifier intended for computation | |||||
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |||||
| related:accessionNumber |
S | 1..1 | Reference(Radiology ServiceRequest) | Related identifiers or resources | ||||
| 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 |
1..1 | AccessionNumber | An identifier intended for computation | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats | ||||
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | ||||
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | ||||
| DocumentReference.context.event:anatomicRegion | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:ImagingProcedure | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | ||||
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG | ||||
| DocumentReference.context.related:accessionNumber.type | extensible | Pattern: ServiceRequesthttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
0..* | ComprehensiveDocumentReference | A reference to a document | |||||
| id |
Σ | 0..1 | id | Logical id of this artifact | ||||
| meta |
Σ | 0..1 | Meta | Metadata about the resource | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| versionId |
Σ | 0..1 | id | Version specific identifier | ||||
| lastUpdated |
Σ | 0..1 | instant | When the resource version last changed | ||||
| source |
Σ | 0..1 | uri | Identifies where the resource comes from | ||||
| profile |
Σ | 0..* | canonical(StructureDefinition) | Profiles this resource claims to conform to | ||||
| security |
Σ | 0..* | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
| tag |
Σ | 0..* | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
| 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.
| |||||
| text |
0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
| contained |
0..* | Resource | Contained, inline Resources | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| masterIdentifier |
1..1 | UniqueIdIdentifier | An identifier intended for computation | |||||
| Slices for identifier |
SΣ | 1..* | Identifier | Other identifiers for the document Slice: Unordered, Open by value:use | ||||
| identifier:entryUUID |
0..* | EntryUUIDIdentifier | An identifier intended for computation | |||||
| status |
?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: MHD DocumentReference status codes (required) | ||||
| type |
SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Document Entry Type (required) | ||||
| category |
SΣ | 1..1 | CodeableConcept | Categorization of document Binding: Document Entry Class (required) | ||||
| subject |
SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | 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 |
0..1 | NHSNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| date |
SΣ | 0..1 | instant | When this document reference was created | ||||
| author |
SΣ | 0..* | Reference(Organization | Practitioner) {c} | Who and/or what authored the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| reference |
ΣC | 0..1 | string | 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 |
0..1 | GeneralMedicalPractitionerCode, GeneralMedicalCouncilReferenceNumber, OrganisationCode | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| authenticator |
0..1 | Reference(Practitioner | PractitionerRole | Organization) {c} | Who/what authenticated the document | |||||
| custodian |
0..1 | Reference(Organization) | Organization which maintains the document | |||||
| relatesTo |
SΣC | 0..* | BackboneElement | Relationships to other documents iti-mhd-repl: a DocumetReference replacements needs to relate to a superseded DocumentReference | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| code |
Σ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
| target |
Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
| description |
Σ | 0..1 | string | Human-readable description | ||||
| securityLabel |
SΣ | 1..* | 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 |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| attachment |
Σ | 1..1 | Attachment | Where to access the document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| contentType |
Σ | 1..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png | ||||
| language |
SΣ | 1..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Example General: en-AU | ||||
| url |
Σ | 1..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png | ||||
| size |
Σ | 0..1 | unsignedInt | Number of bytes of content (if url provided) | ||||
| hash |
Σ | 0..1 | base64Binary | Hash of the data (sha-1, base64ed) | ||||
| title |
Σ | 0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | ||||
| creation |
SΣ | 1..1 | dateTime | Date attachment was first created | ||||
| format |
SΣ | 1..1 | Coding | Format/content rules for the document Binding: IHE ValueSet of Format Codes for use with Document Sharing (preferred) | ||||
| context |
Σ | 1..1 | BackboneElement | Clinical context of document | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations | |||||
| modifierExtension |
?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ||||
| encounter |
0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content | |||||
| Slices for event |
0..* | CodeableConcept | Main clinical acts documented Slice: Unordered, Open by pattern:type Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:modality |
0..* | CodeableConcept | Main clinical acts documented Binding: https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html (required) | |||||
| event:anatomicRegion |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| event:ImagingProcedure |
0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
| period |
SΣ | 0..1 | Period | Time of service that is being documented | ||||
| id |
0..1 | string | Unique id for inter-element referencing | |||||
| extension |
0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| start |
ΣC | 0..1 | dateTime | Starting time with inclusive boundary | ||||
| end |
ΣC | 0..1 | dateTime | End time with inclusive boundary, if not ongoing | ||||
| facilityType |
S | 1..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type (required) | ||||
| practiceSetting |
S | 1..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Specialty (required) | ||||
| sourcePatientInfo |
S | 1..1 | Reference(Patient) {c} | Patient demographics from source | ||||
| 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 |
0..1 | MedicalRecordNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| Slices for related |
1..* | Reference(Resource) | Related identifiers or resources Slice: Unordered, Open by pattern:type | |||||
| related:accessionNumber |
S | 1..1 | Reference(Radiology ServiceRequest) | Related identifiers or resources | ||||
| 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 |
1..1 | AccessionNumber | An identifier intended for computation | |||||
| display |
Σ | 0..1 | string | Text alternative for the resource | ||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet / Code | URI | |||
| DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.meta.tag | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tagsfrom the FHIR Standard | ||||
| DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.status | required | DocumentReferenceStatshttps://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats | ||||
| DocumentReference.type | required | DocumentEntryTypehttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-typefrom this IG | ||||
| DocumentReference.category | required | DocumentEntryClasshttps://fhir.nhs.uk/England/RAD/ValueSet/document-entry-classfrom this IG | ||||
| DocumentReference.subject.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.author.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1from the FHIR Standard | ||||
| DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labelsfrom the FHIR Standard | ||||
| DocumentReference.content.attachment.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13)http://hl7.org/fhir/ValueSet/mimetypes|4.0.1from the FHIR Standard | ||||
| DocumentReference.content.attachment.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languagesfrom the FHIR Standard | ||||
| DocumentReference.content.format | preferred | IHE_FormatCode_vshttp://ihe.net/fhir/ihe.formatcode.fhir/ValueSet/formatcode | ||||
| DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:modality | required | https://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.htmlhttps://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html | ||||
| DocumentReference.context.event:anatomicRegion | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.event:ImagingProcedure | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
| DocumentReference.context.facilityType | required | FacilityTypehttps://fhir.nhs.uk/England/RAD/ValueSet/facility-typefrom this IG | ||||
| DocumentReference.context.practiceSetting | required | Specialtyhttps://fhir.nhs.uk/England/RAD/ValueSet/specialtyfrom this IG | ||||
| DocumentReference.context.sourcePatientInfo.type | extensible | ResourceTypehttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard | ||||
| DocumentReference.context.related:accessionNumber.type | extensible | Pattern: ServiceRequesthttp://hl7.org/fhir/ValueSet/resource-typesfrom the FHIR Standard |
This structure is derived from ComprehensiveDocumentReference
Summary
Mandatory: 5 elements
Must-Support: 2 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
IG © 2024+ NHS England. Package nhs.england.rad#0.0.1-current based on FHIR 4.0.1. Generated 2024-10-24
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