Interoperabilidad de Historia Clínica - Colombia
0.4.2 - ci-build Colombia flag

Interoperabilidad de Historia Clínica - Colombia - Local Development build (v0.4.2). See the Directory of published versions

Resource Profile: Referencia de Documentos

Official URL: https://www.minsalud.gov.co/ihc/fhir/StructureDefinition/DocumentReferenceCo Version: 0.4.2
Draft as of 2023-10-31 Computable Name: DocumentReferenceCo

Docuento utilizado para guardar referencias.

Usage:

Formal Views of Profile Content

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

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codeEstado del Documento. Valor Fijo: current
Required Pattern: current
... type S1..1CodeableConceptValor fijo : #60591-5
.... coding S1..1CodingCódigo del tipo de documento.
..... system 0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... code 0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
... subject S1..1Reference(Paciente Co)Representa al paciente.
.... reference 1..1stringURL que referencia al recurso paciente.
... author S1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... reference 1..1stringURL que indica el autor.
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... reference 1..1stringURL que indica la Organización.
... content
.... attachment S1..1AttachmentWhere to access the document
..... url S1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codeEstado del Documento. Valor Fijo: current
Binding: DocumentReferenceStatus (required): The status of the document reference.


Required Pattern: current
.... coding SΣ1..1CodingCódigo del tipo de documento.
..... system Σ0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... code Σ0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
... subject SΣ1..1Reference(Paciente Co)Representa al paciente.
.... reference ΣC1..1stringURL que referencia al recurso paciente.
... date SΣ1..1instantFecha de creación del documento
... author SΣ1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... reference ΣC1..1stringURL que indica el autor.
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... reference ΣC1..1stringURL que indica la Organización.
... content Σ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... url SΣ1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.
Example General: http://www.acme.com/logo-small.png

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DocumentReference.statusrequiredPattern: current
DocumentReference.typepreferredDocumentTypeValueSet
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codeEstado del Documento. Valor Fijo: current
Binding: DocumentReferenceStatus (required): The status of the document reference.


Required Pattern: current
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptValor fijo : #60591-5
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ1..1CodingCódigo del tipo de documento.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Paciente Co)Representa al paciente.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que referencia al recurso paciente.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... date SΣ1..1instantFecha de creación del documento
... author SΣ1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que indica el autor.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que indica la Organización.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType Σ0..1codeMime 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
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data 0..1base64BinaryData inline, base64ed
..... url SΣ1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter 0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredPattern: current
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.subject.typeextensibleResourceType
DocumentReference.author.typeextensibleResourceType
DocumentReference.custodian.typeextensibleResourceType
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 10 elements
Must-Support: 9 elements

Structures

This structure refers to these other structures:

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... status S1..1codeEstado del Documento. Valor Fijo: current
Required Pattern: current
... type S1..1CodeableConceptValor fijo : #60591-5
.... coding S1..1CodingCódigo del tipo de documento.
..... system 0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... code 0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
... subject S1..1Reference(Paciente Co)Representa al paciente.
.... reference 1..1stringURL que referencia al recurso paciente.
... author S1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... reference 1..1stringURL que indica el autor.
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... reference 1..1stringURL que indica la Organización.
... content
.... attachment S1..1AttachmentWhere to access the document
..... url S1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.

doco Documentation for this format

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!SΣ1..1codeEstado del Documento. Valor Fijo: current
Binding: DocumentReferenceStatus (required): The status of the document reference.


Required Pattern: current
.... coding SΣ1..1CodingCódigo del tipo de documento.
..... system Σ0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... code Σ0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
... subject SΣ1..1Reference(Paciente Co)Representa al paciente.
.... reference ΣC1..1stringURL que referencia al recurso paciente.
... date SΣ1..1instantFecha de creación del documento
... author SΣ1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... reference ΣC1..1stringURL que indica el autor.
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... reference ΣC1..1stringURL que indica la Organización.
... content Σ1..*BackboneElementDocument referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... url SΣ1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.
Example General: http://www.acme.com/logo-small.png

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DocumentReference.statusrequiredPattern: current
DocumentReference.typepreferredDocumentTypeValueSet

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... status ?!SΣ1..1codeEstado del Documento. Valor Fijo: current
Binding: DocumentReferenceStatus (required): The status of the document reference.


Required Pattern: current
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConceptValor fijo : #60591-5
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.

.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding SΣ1..1CodingCódigo del tipo de documento.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... system Σ0..1uriSistema de codificación
Required Pattern: http://loinc.org
..... version Σ0..1stringVersion of the system - if relevant
..... code Σ0..1codeValor fijo : #60591-5
Required Pattern: 60591-5
..... display Σ0..1stringRepresentation defined by the system
..... userSelected Σ0..1booleanIf this coding was chosen directly by the user
.... text Σ0..1stringPlain text representation of the concept
... category Σ0..*CodeableConceptCategorization of document
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


... subject SΣ1..1Reference(Paciente Co)Representa al paciente.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que referencia al recurso paciente.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... date SΣ1..1instantFecha de creación del documento
... author SΣ1..1Reference(Organizacion Co)Corresponde la institución donde se creó el documento RDA.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que indica el autor.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian S1..1Reference(Organizacion Co)Corresponde a la región encargada de mantener el documento RDA.
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC1..1stringURL que indica la Organización.
.... type Σ0..1uriType the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).

.... identifier Σ0..1IdentifierLogical reference, when literal reference is not known
.... display Σ0..1stringText alternative for the resource
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content Σ1..*BackboneElementDocument referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣ1..1AttachmentWhere to access the document
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType Σ0..1codeMime 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
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data 0..1base64BinaryData inline, base64ed
..... url SΣ1..1urlSe debe completar URL del recurso Composition RDA, enviado dentro del bundle.
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format Σ0..1CodingFormat/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.

... context Σ0..1BackboneElementClinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter 0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period Σ0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional 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..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredPattern: current
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typepreferredDocumentTypeValueSet
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.subject.typeextensibleResourceType
DocumentReference.author.typeextensibleResourceType
DocumentReference.custodian.typeextensibleResourceType
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatpreferredDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

This structure is derived from DocumentReference

Summary

Mandatory: 10 elements
Must-Support: 9 elements

Structures

This structure refers to these other structures:

 

Other representations of profile: CSV, Excel, Schematron