This page is part of the PanCareSurPass Project HL7 FHIR Implementation Guide (v0.1.0: QA Preview) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

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Resource Profile: DocumentReference: PCSP

This profile defines how to embed a PDF PCSP Survivor Passport in FHIR for the purpose of the PanCareSurPass project. This profile can be aslo used for send attachments (e.g Raditherapy reports or HDR) to the platform

Usage:

• Examples for this Resource Profile: DocumentReference/DocumentReferenceExample-1

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status		1..1	code	The status of this reference
docStatus		0..1	code	The status of the document
type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
subject		1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date		0..1	instant	When this reference was created
relatesTo		0..*	BackboneElement	Relationships to other documents.
content
attachment
contentType		0..1	code	Mime type of the content, with charset etc. Example PDF: application/pdf
language		1..1	code	Human language of the content (BCP-47)
data		1..1	base64Binary	Data inline, base64ed
title		0..1	string	Document title
creation		1..1	dateTime	Date attachment was first created
context
related		0..*	Reference(Condition: Primary Cancer | Procedure: Radiotherapy)	required for documents to be uploaded
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.type	extensible	DocRefDocType

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	The status of this reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	The status of the document Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
subject	Σ	1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date	Σ	0..1	instant	When this reference was created
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents.
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
content	Σ	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	0..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 Example PDF: application/pdf
language	Σ	1..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
data		1..1	base64Binary	Data inline, base64ed
title	Σ	0..1	string	Document title Example General: Official Corporate Logo
creation	Σ	1..1	dateTime	Date attachment was first created
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	extensible	DocRefDocType
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	The status of this reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	The status of the document Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date	Σ	0..1	instant	When this reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents.
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	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	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	0..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 Example PDF: application/pdf
language	Σ	1..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
data		1..1	base64Binary	Data inline, base64ed
url	Σ	0..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	Document title Example General: Official Corporate Logo
creation	Σ	1..1	dateTime	Date attachment was first created
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
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).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Condition: Primary Cancer | Procedure: Radiotherapy)	required for documents to be uploaded
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	extensible	DocRefDocType
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 5 elements

Structures

This structure refers to these other structures:

• Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
• Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)
• Procedure: Radiotherapy (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-radiotheraphy-eu-pcsp)

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status		1..1	code	The status of this reference
docStatus		0..1	code	The status of the document
type		1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
subject		1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date		0..1	instant	When this reference was created
relatesTo		0..*	BackboneElement	Relationships to other documents.
content
attachment
contentType		0..1	code	Mime type of the content, with charset etc. Example PDF: application/pdf
language		1..1	code	Human language of the content (BCP-47)
data		1..1	base64Binary	Data inline, base64ed
title		0..1	string	Document title
creation		1..1	dateTime	Date attachment was first created
context
related		0..*	Reference(Condition: Primary Cancer | Procedure: Radiotherapy)	required for documents to be uploaded
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.type	extensible	DocRefDocType

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	The status of this reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	The status of the document Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
subject	Σ	1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date	Σ	0..1	instant	When this reference was created
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents.
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
content	Σ	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	0..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 Example PDF: application/pdf
language	Σ	1..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
data		1..1	base64Binary	Data inline, base64ed
title	Σ	0..1	string	Document title Example General: Official Corporate Logo
creation	Σ	1..1	dateTime	Date attachment was first created
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	extensible	DocRefDocType
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	The status of this reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	The status of the document Binding: CompositionStatus (required): Status of the underlying document.
type	Σ	1..1	CodeableConcept	Kind of document (LOINC if possible) Binding: Document Type (extensible) Example Passport: {"coding":[{"system":"http://hl7.eu/fhir/ig/pcsp/CodeSystem/cs-generic-eu-pcsp","code":"surpass","display":"Childhood Cancer Survivor Passport"}]}
category	Σ	0..*	CodeableConcept	Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	Σ	1..1	Reference(Patient: PCSP)	Who/what is the subject of the document
date	Σ	0..1	instant	When this reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents.
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	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	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	0..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 Example PDF: application/pdf
language	Σ	1..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
data		1..1	base64Binary	Data inline, base64ed
url	Σ	0..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	Document title Example General: Official Corporate Logo
creation	Σ	1..1	dateTime	Date attachment was first created
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	Σ	0..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
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
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).
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Condition: Primary Cancer | Procedure: Radiotherapy)	required for documents to be uploaded
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	extensible	DocRefDocType
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 5 elements

Structures

This structure refers to these other structures:

• Patient: PCSP (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Patient-eu-pcsp)
• Condition: Primary Cancer (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Condition-primaryCancer-eu-pcsp)
• Procedure: Radiotherapy (http://hl7.eu/fhir/ig/pcsp/StructureDefinition/Procedure-radiotheraphy-eu-pcsp)

Other representations of profile: CSV, Excel, Schematron