Introduction
The headings below list the elements of the DocumentReference resource and describe how to populate and consume them.
DocumentReference elements
id
Data type: Id |
Optionality: Mandatory | Cardinality: 1..1 |
The logical identifier of the DocumentReference resource.
meta.profile
Data type: uri |
Optionality: Mandatory | Cardinality: 1..* |
The DocumentReference profile URL.
Fixed value https://fhir.nhs.uk/STU3/StructureDefinition/CareConnect-GPC-DocumentReference-1
masterIdentifier
Data type: Id |
Optionality: Required | Cardinality: 0..1 |
Master Version Specific Identifier. This unique identifier is used to identify the version of the document
identifier
Data type: Identifier |
Optionality: Mandatory | Cardinality: 1..* |
This MUST be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data). This MUST be scoped by a provider specific namespace for the identifier.
Where consuming systems are integrating data from this resource to their local system, they MUST also persist this identifier at the same time.
status
Data type: code |
Optionality: Mandatory | Cardinality: 1..1 |
current | superseded | entered-in-error This field will always have default value of current as only the latest version of the document is retrieved.
type
Data type: codeableConcept |
Optionality: Mandatory | Cardinality: 1..1 |
Kind of document, a value SHOULD be taken from the SNOMED refset 1127551000000109 |Record composition type simple reference set (foundation metadata concept)|.
Other classifications of documents SHOULD be sent as text.
subject
Data type: Reference(CareConnect-GPC-Patient-1 | CareConnect-GPC-Practitioner-1) |
Optionality: Mandatory | Cardinality: 1..1 |
A reference to the patient who is the subject of the document.
created
| Data type: DateTime | Optionality: Required | Cardinality: 0..1 |
Creation/Edit datetime of the document.
indexed
Data type: Instant |
Optionality: Mandatory | Cardinality: 1..1 |
When the GP Practice added the document to their clinical system.
author
Data type: Reference ( CareConnect-GPC-Practitioner-1 | CareConnect-GPC-Organization-1 ) |
Optionality: Required | Cardinality: 0..1 |
Who and/or what authored the document.
custodian
Data type: Reference(Organisation) |
Optionality: Required | Cardinality: 0..1 |
Organisation which maintains this document.
description
Data type: string |
Optionality: Required | Cardinality: 0..1 |
Human-readable description (title).
content.attachment.url
Data type: url |
Optionality: Required | Cardinality: 0..1 |
URL to retrieve the document, this MUST be populated when the document is available. This MUST contain the full URL to the Binary resource, including when the DocumentReference is being included in an Access Record Structured Bundle.
content.attachment.size
Data type: unsignedInt |
Optionality: Mandatory | Cardinality: 1..1 |
Size of the file.
content.attachment.title
Data type: string |
Optionality: Optional | Cardinality: 0..1 |
To be used when only a placeholder for a document is available. This SHOULD be populated with the reason why the file isn’t available.
content.attachment.contentType
Data type: Code |
Optionality: Mandatory | Cardinality: 1..1 |
MIME type for the document.
context.encounter
Data type: Reference(CareConnect-GPC-Encounter-1) |
Optionality: Required/Optional | Cardinality: 0..1 |
Reference to the consultation the document was created/attached in.
context.practiceSetting
Data type: codeableConcept |
Optionality: Required | Cardinality: 0..1 |
Additional details about where the content was created (for example, clinical specialty), the value SHOULD be taken from the refset. Other classifications of documents should be sent as text.
context.related
Data type: BackboneElement |
Optionality: Optional | Cardinality: 0..* |
Reference to other resource(s) to which the document is linked to, for instance this could be a reference to an inbound referral.
Elements not in use
The following elements MUST NOT be populated:
docStatus
Data type: Reference(preliminary | final | appended | amended | entered-in-error) |
This is not required by GP Connect.
class
Data type: codeableConcept |
Categorization of document is not required by GP Connect.
authenticator
Data type: Reference ( CareConnect-GPC-Practitioner-1 | CareConnect-GPC-Organization-1 ) |
Who/what authenticated the document is not required by GP Connect.
content.attachment.data
Data type: base64Binary |
Data of the attachment is not required by GP Connect as it will be populated in FHIR binary resource.
relatesTo
Data type: code |
replaces | transforms | signs | appends Relationships to other documents is not required by GP Connect.
Data type:Reference(CareConnect-GPC-Patient-1) |
Optionality: Required | Cardinality: 0..1 |
Patient demographics from source.
securityLabel
Data type: codeableConcept |
Document security-tags is not required by GP Connect.
