description: To promote interoperability and adoption through common implementation, this profile sets minimum expectations for searching and fetching patient documents including Clinical Notes using the DocumentReference resource. It identifies which core elements, extensions, vocabularies, and value sets **SHALL** be present and constrains the way the elements are used when using the profile. It provides the floor for standards development for specific use cases. Prior to reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of US Core DocumentReference Profile and US Core DiagnosticReport Profile for Report and Note exchange.
package_name: hl7.fhir.us.core
derivation: constraint
name: USCoreDocumentReferenceProfile
type: DocumentReference
elements:
  category:
    short: (USCDI) Categorization of document
    mustSupport: true
    index: 3
    slicing:
      rules: open
      discriminator:
      - {path: $this, type: pattern}
      min: 1
      slices:
        uscore:
          match: {}
          schema:
            short: (USCDI) Categorization of document
            binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category'}
            index: 4
  date: {short: (USCDI) When this document reference was created, mustSupport: true, index: 6}
  content:
    short: (USCDI) Document referenced
    mustSupport: true
    index: 8
    elements:
      attachment:
        short: (USCDI) Where to access the document
        constraint:
          us-core-6: {human: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present., severity: error, expression: url.exists() or data.exists()}
        mustSupport: true
        index: 9
        elements:
          contentType: {short: '(USCDI) Mime type of the content, with charset etc.', mustSupport: true, index: 10}
          data: {short: '(USCDI) Data inline, base64ed', mustSupport: true, index: 11}
          url: {short: (USCDI) Uri where the data can be found, mustSupport: true, index: 12}
      format:
        short: (USCDI) Format/content rules for the document
        binding: {strength: extensible, valueSet: 'http://hl7.org/fhir/ValueSet/formatcodes'}
        mustSupport: true
        index: 13
  type:
    short: (USCDI) Kind of document (LOINC if possible)
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type'}
    mustSupport: true
    index: 2
  author:
    type: Reference
    short: (USCDI) Who and/or what authored the document
    mustSupport: true
    refers: ['http://hl7.org/fhir/StructureDefinition/Device', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole', 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson']
    index: 7
  status:
    short: (USCDI) current | superseded | entered-in-error
    binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/document-reference-status'}
    mustSupport: true
    index: 1
  identifier: {short: (USCDI) Other identifiers for the document, mustSupport: true, index: 0}
  context:
    short: (USCDI) Clinical context of document
    mustSupport: true
    index: 14
    elements:
      encounter:
        type: Reference
        short: (USCDI) Context of the document  content
        mustSupport: true
        refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter']
        index: 15
      period: {short: (USCDI) Time of service that is being documented, mustSupport: true, index: 16}
  subject:
    type: Reference
    short: (USCDI) Who/what is the subject of the document
    mustSupport: true
    refers: ['http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient']
    index: 5
package_version: 6.0.0
class: profile
kind: resource
url: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference
base: http://hl7.org/fhir/StructureDefinition/DocumentReference
version: 6.0.0
required: [subject, type, category]