Profil DocumentReference pour un document administratif de préadmission

Objectif

Dans le cadre de la préadmission hospitalière, le patient est invité à fournir certains documents administratifs nécessaires à la validation de son dossier. Ces documents permettent à l’établissement de santé de vérifier l’identité, la couverture sociale du patient avant son admission.

Les documents sont modélisés dans FHIR à l’aide de la ressource DocumentReference, enrichie d’extensions spécifiques pour répondre aux besoins du processus de préadmission.

Documents typiques à fournir

Ces documents sont modélisés dans FHIR à l’aide de la ressource DocumentReference, avec le type de document contraint par le ValueSet PreadmissionValueSetDocumentTypeFr.

Ressource FHIR : DocumentReference

La ressource DocumentReference est utilisée pour représenter chaque document transmis par le patient. Elle contient des métadonnées essentielles telles que le type de document, la date de création, et un lien vers le fichier téléversé.

Contraintes principales

• Type de document : Obligatoire, défini via l’extension PreadmissionTypeDocumentFr.
• Lien avec la préadmission : Chaque document doit être associé à un Encounter via DocumentReference.context.encounter.

Critère de recherche autorisé

Dans le contexte de la préadmission, la ressource DocumentReference peut être recherchée :

• à partir de l’encounter (documents liés à une préadmission)
• et, si nécessaire, à partir du patient (liste des documents du patient)

documentreference?encounter=

documentreference?patient=

Bonnes pratiques

• Validation des documents : Chaque document téléversé doit être vérifié par un agent administratif pour s’assurer de sa conformité (lisibilité, validité, etc.).
• Traçabilité : Les documents doivent être horodatés et associés à un Encounter pour garantir une traçabilité complète.
• Respect des réglementations : Les documents doivent être stockés conformément aux exigences légales (RGPD, hébergement HDS, etc.).
• Gestion des erreurs : En cas de document manquant ou non conforme, une notification doit être envoyée au patient pour lui permettre de corriger ou compléter son dossier.

Conclusion

La ressource DocumentReference joue un rôle clé dans la gestion des pièces justificatives pour la préadmission hospitalière. Elle garantit une organisation structurée et conforme des documents, tout en facilitant leur traitement par les agents administratifs.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.status	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
DocumentReference.type	Σ This element is included in summaries.	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.content	Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	Σ This element is included in summaries.	1..1	Attachment	Where to access the document
DocumentReference.content.attachment.contentType	Σ This element is included in summaries.	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
DocumentReference.context	Σ This element is included in summaries.	1..1	BackboneElement	Clinical context of document
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.content
DocumentReference.content.attachment
DocumentReference.content.attachment.contentType		1..1	code	Mime type of the content, with charset etc.
DocumentReference.context		1..1	BackboneElement	Clinical context of document
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	Σ This element is included in summaries.	0..1	Identifier	Master Version Specific Identifier
DocumentReference.identifier	Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
DocumentReference.type	Σ This element is included in summaries.	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.category	Σ This element is included in summaries.	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
DocumentReference.subject	Σ This element is included in summaries.	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
DocumentReference.date	Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	Σ This element is included in summaries.	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
DocumentReference.authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
DocumentReference.custodian		0..1	Reference(Organization)	Organization which maintains the document
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	Relationships to other documents
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(DocumentReference)	Target of the relationship
DocumentReference.description	Σ This element is included in summaries.	0..1	string	Human-readable description
DocumentReference.securityLabel	Σ This element is included in summaries.	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
DocumentReference.content	Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	Σ This element is included in summaries.	1..1	Attachment	Where to access the document
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	Σ This element is included in summaries.	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
DocumentReference.content.attachment.language	Σ This element is included in summaries.	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
DocumentReference.content.attachment.data		0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	Σ This element is included in summaries.	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
DocumentReference.context	Σ This element is included in summaries.	1..1	BackboneElement	Clinical context of document
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
DocumentReference.context.event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
DocumentReference.context.period	Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
DocumentReference.context.facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
DocumentReference.context.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).
DocumentReference.context.sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
DocumentReference.context.related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📍4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.status	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
DocumentReference.type	Σ This element is included in summaries.	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.content	Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	Σ This element is included in summaries.	1..1	Attachment	Where to access the document
DocumentReference.content.attachment.contentType	Σ This element is included in summaries.	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
DocumentReference.context	Σ This element is included in summaries.	1..1	BackboneElement	Clinical context of document
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.content
DocumentReference.content.attachment
DocumentReference.content.attachment.contentType		1..1	code	Mime type of the content, with charset etc.
DocumentReference.context		1..1	BackboneElement	Clinical context of document
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG

Snapshot ViewView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	Σ This element is included in summaries.	0..1	Identifier	Master Version Specific Identifier
DocumentReference.identifier	Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
DocumentReference.type	Σ This element is included in summaries.	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: preadmission-document-type-vs (required)
DocumentReference.category	Σ This element is included in summaries.	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
DocumentReference.subject	Σ This element is included in summaries.	0..1	Reference(Patient | Practitioner | Group | Device)	Who/what is the subject of the document
DocumentReference.date	Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	Σ This element is included in summaries.	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
DocumentReference.authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
DocumentReference.custodian		0..1	Reference(Organization)	Organization which maintains the document
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	Relationships to other documents
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(DocumentReference)	Target of the relationship
DocumentReference.description	Σ This element is included in summaries.	0..1	string	Human-readable description
DocumentReference.securityLabel	Σ This element is included in summaries.	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
DocumentReference.content	Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	Σ This element is included in summaries.	1..1	Attachment	Where to access the document
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	Σ This element is included in summaries.	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
DocumentReference.content.attachment.language	Σ This element is included in summaries.	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
DocumentReference.content.attachment.data		0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	Σ This element is included in summaries.	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
DocumentReference.context	Σ This element is included in summaries.	1..1	BackboneElement	Clinical context of document
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter		1..1	Reference(Fr Preadmission Encounter Profile)	Context of the document content
DocumentReference.context.event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
DocumentReference.context.period	Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
DocumentReference.context.facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
DocumentReference.context.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).
DocumentReference.context.sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
DocumentReference.context.related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	preadmission-document-type-vs	📦1.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	DocumentReference Format Code Set	📍4.0.1	FHIR Std.
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📍4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()

This structure is derived from DocumentReference

Summary

Mandatory: 4 elements

Structures

This structure refers to these other structures:

• Fr Preadmission Encounter Profile (https://hl7.fr/ig/fhir/preadmission/StructureDefinition/preadmission-encounter-fr)