Guidance for populating and consuming the DocumentReference resource

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current | superseded | entered-in-error This field will always have default value of current as only the latest version of the document is retrieved.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.