ÚNICAS Rare Diseases HL7 FHIR Implementation Guide - Local Development build (v0.0.1) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: DocumentReference Documento en Base64 ÚNICAS

Este profile define las restricciones del recurso DocumentReference para representar un documento clínico en el contexto del caso de uso de ÚNICAS.

Usages:

• Use this Profile: Bundle Documentos ÚNICAS
• Refer to this Profile: CarePlan Gestor del Proceso ÚNICAS
• Examples for this Profile: DocumentReference/UNICAS-Consentimiento-ejemploDocumentReferenceCI-00
• CapabilityStatements using this Profile: Configuración del Servidor FHIR de ÚNICAS

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

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

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Identificador único
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	ΣC	1..1	uri	Sistema para identificar el origen Constraints: regcess-system Example General: urn:regcess:0123456789
value	ΣC	1..1	string	Identificador interno del sistema para el documento Example General: 123456
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
subject	Σ	1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
reference	ΣC	0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
system	Σ	0..1	uri	OID registro de número de CIP-SNS Example General: urn:oid:2.16.724.4.40
value	ΣC	0..1	string	Número CIP-SNS Example General: BBBBBBBBQR648597
display	ΣC	0..1	string	Nombre completo del paciente
context	C	0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	0..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	0..1	Identifier	Identificador del recurso FHIR
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	0..1	uri	Sistema para identificar el origen Example General: urn:regcess:0123456789
value	ΣC	0..1	string	Identificador interno del sistema para la interacción clínica Example General: 123456
date	Σ	1..1	instant	Fecha de publicación del informe/información
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	0..1	uri	OID registro de número de REGCESS Example General: urn:oid:2.16.724.4.21.5.10
value	ΣC	0..1	string	Código REGCESS Example General: 0123456789
display	ΣC	0..1	string	Nombre completo de la institución
description	Σ	1..1	markdown	Título del informe/información ÚNICAS
content	Σ	1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
contentType	ΣC	0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one) Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png
data	C	0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url	Σ	1..1	url	URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.subject.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.context.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.context.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.custodian.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.custodian.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.content.attachment.contentType	required	MimeTypes(a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|5.0.0 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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()
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference			DocumentReference
identifier		1..*	Identifier	Identificador único
system	C	1..1	uri	Sistema para identificar el origen Constraints: regcess-system
value		1..1	string	Identificador interno del sistema para el documento
type		1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
coding
system		1..1	uri	URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS
code		1..1	code	Código del tipo de informe/información ÚNICAS
display		1..1	string	Descripción del tipo de informe/información ÚNICAS
subject		1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
reference		0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type		1..1	uri	Tipo de recurso FHIR
identifier		1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
type		0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
coding
system		0..1	uri	URL del SNOMED CT. Extensión para España del SNS
code		0..1	code	Código del identificador
display		0..1	string	Decripción del identificador
system		0..1	uri	OID registro de número de CIP-SNS
value		0..1	string	Número CIP-SNS
display		0..1	string	Nombre completo del paciente
context		0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
reference		0..1	string	Referencia recurso FHIR
type		0..1	uri	Tipo de recurso FHIR
identifier		0..1	Identifier	Identificador del recurso FHIR
system		0..1	uri	Sistema para identificar el origen
value		0..1	string	Identificador interno del sistema para la interacción clínica
date		1..1	instant	Fecha de publicación del informe/información
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
reference		0..1	string	Referencia recurso FHIR
type		1..1	uri	Tipo de recurso FHIR
identifier		1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
system		0..1	uri	OID registro de número de REGCESS
value		0..1	string	Código REGCESS
display		0..1	string	Nombre completo de la institución
description		1..1	markdown	Título del informe/información ÚNICAS
content		1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
attachment
contentType		0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one)
data		0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url		1..1	url	URL del datos en formato Base64 (recurso Binary)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter
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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Identificador único
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	ΣC	1..1	uri	Sistema para identificar el origen Constraints: regcess-system Example General: urn:regcess:0123456789
value	ΣC	1..1	string	Identificador interno del sistema para el documento Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
version	Σ	0..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document.
modality	Σ	0..*	CodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS
version	Σ	0..1	string	Version of the system - if relevant
code	ΣC	1..1	code	Código del tipo de informe/información ÚNICAS
display	ΣC	1..1	string	Descripción del tipo de informe/información ÚNICAS
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	URL del SNOMED CT. Extensión para España del SNS
version	Σ	0..1	string	Version of the system - if relevant
code	ΣC	0..1	code	Código del identificador
display	ΣC	0..1	string	Decripción del identificador
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	OID registro de número de CIP-SNS Example General: urn:oid:2.16.724.4.40
value	ΣC	0..1	string	Número CIP-SNS Example General: BBBBBBBBQR648597
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Nombre completo del paciente
context	C	0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	0..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	0..1	Identifier	Identificador del recurso FHIR
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	Sistema para identificar el origen Example General: urn:regcess:0123456789
value	ΣC	0..1	string	Identificador interno del sistema para la interacción clínica Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Text alternative for the resource
event		0..*	CodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	CodeableReference(BodyStructure)	Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
facilityType	C	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	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).
period	Σ	0..1	Period	Time of service that is being documented
date	Σ	1..1	instant	Fecha de publicación del informe/información
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of the 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
mode		1..1	CodeableConcept	personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document.
time		0..1	dateTime	When the document was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the document
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	OID registro de número de REGCESS Example General: urn:oid:2.16.724.4.21.5.10
value	ΣC	0..1	string	Código REGCESS Example General: 0123456789
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Nombre completo de la institución
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	CodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	1..1	markdown	Título del informe/información ÚNICAS
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
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	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	ΣC	0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one) Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language. Additional Bindings Purpose CommonLanguages Starter Example General: en-AU
data	C	0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url	Σ	1..1	url	URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	integer64	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	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
height		0..1	positiveInt	Height of the image in pixels (photo/video)
width		0..1	positiveInt	Width of the image in pixels (photo/video)
frames		0..1	positiveInt	Number of frames if > 1 (photo)
duration		0..1	decimal	Length in seconds (audio / video)
pages		0..1	positiveInt	Number of printed pages
profile	Σ	0..*	BackboneElement	Content profile rules for the 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
value[x]	Σ	1..1		Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes.
valueCoding			Coding
valueUri			uri
valueCanonical			canonical(Any)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	​Modality (missing link) http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From this IG
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.subject.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.context.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.context.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.context.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site From the FHIR Standard
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
DocumentReference.custodian.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.custodian.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.custodian.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard
DocumentReference.content.attachment.contentType	required	MimeTypes(a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|5.0.0 From the FHIR Standard
DocumentReference.content.attachment.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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()
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

This structure is derived from DocumentReference

Summary

Mandatory: 13 elements(3 nested mandatory elements)

Structures

This structure refers to these other structures:

• Patient Paciente ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASPatient)
• Encounter Interacción Clínica ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASEncounter)
• Organization Institución ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASOrganization)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
contained		0..*	Resource	Contained, inline Resources
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Identificador único
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	ΣC	1..1	uri	Sistema para identificar el origen Constraints: regcess-system Example General: urn:regcess:0123456789
value	ΣC	1..1	string	Identificador interno del sistema para el documento Example General: 123456
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
subject	Σ	1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
reference	ΣC	0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
system	Σ	0..1	uri	OID registro de número de CIP-SNS Example General: urn:oid:2.16.724.4.40
value	ΣC	0..1	string	Número CIP-SNS Example General: BBBBBBBBQR648597
display	ΣC	0..1	string	Nombre completo del paciente
context	C	0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	0..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	0..1	Identifier	Identificador del recurso FHIR
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	0..1	uri	Sistema para identificar el origen Example General: urn:regcess:0123456789
value	ΣC	0..1	string	Identificador interno del sistema para la interacción clínica Example General: 123456
date	Σ	1..1	instant	Fecha de publicación del informe/información
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
system	Σ	0..1	uri	OID registro de número de REGCESS Example General: urn:oid:2.16.724.4.21.5.10
value	ΣC	0..1	string	Código REGCESS Example General: 0123456789
display	ΣC	0..1	string	Nombre completo de la institución
description	Σ	1..1	markdown	Título del informe/información ÚNICAS
content	Σ	1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
contentType	ΣC	0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one) Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png
data	C	0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url	Σ	1..1	url	URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.subject.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.context.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.context.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.custodian.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.custodian.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.content.attachment.contentType	required	MimeTypes(a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|5.0.0 From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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()
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference			DocumentReference
identifier		1..*	Identifier	Identificador único
system	C	1..1	uri	Sistema para identificar el origen Constraints: regcess-system
value		1..1	string	Identificador interno del sistema para el documento
type		1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
coding
system		1..1	uri	URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS
code		1..1	code	Código del tipo de informe/información ÚNICAS
display		1..1	string	Descripción del tipo de informe/información ÚNICAS
subject		1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
reference		0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type		1..1	uri	Tipo de recurso FHIR
identifier		1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
type		0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
coding
system		0..1	uri	URL del SNOMED CT. Extensión para España del SNS
code		0..1	code	Código del identificador
display		0..1	string	Decripción del identificador
system		0..1	uri	OID registro de número de CIP-SNS
value		0..1	string	Número CIP-SNS
display		0..1	string	Nombre completo del paciente
context		0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
reference		0..1	string	Referencia recurso FHIR
type		0..1	uri	Tipo de recurso FHIR
identifier		0..1	Identifier	Identificador del recurso FHIR
system		0..1	uri	Sistema para identificar el origen
value		0..1	string	Identificador interno del sistema para la interacción clínica
date		1..1	instant	Fecha de publicación del informe/información
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
reference		0..1	string	Referencia recurso FHIR
type		1..1	uri	Tipo de recurso FHIR
identifier		1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
system		0..1	uri	OID registro de número de REGCESS
value		0..1	string	Código REGCESS
display		0..1	string	Nombre completo de la institución
description		1..1	markdown	Título del informe/información ÚNICAS
content		1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
attachment
contentType		0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one)
data		0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url		1..1	url	URL del datos en formato Base64 (recurso Binary)
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard

Constraints

Id	Grade	Path(s)	Details	Requirements
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference	C	0..*	DocumentReference	A reference to a document Constraints: docRef-1, docRef-2
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: AllLanguages (required): IETF language tag for a human language Additional Bindings Purpose CommonLanguages Starter
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
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	1..*	Identifier	Identificador único
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	ΣC	1..1	uri	Sistema para identificar el origen Constraints: regcess-system Example General: urn:regcess:0123456789
value	ΣC	1..1	string	Identificador interno del sistema para el documento Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
version	Σ	0..1	string	An explicitly assigned identifer of a variation of the content in the DocumentReference
basedOn		0..*	Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription)	Procedure that caused this media to be created
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	Σ	0..1	code	registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: CompositionStatus (required): Status of the underlying document.
modality	Σ	0..*	CodeableConcept	Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance.
type	Σ	1..1	CodeableConcept	Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (preferred): Value set de Tipos de informes para ÚNICAS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	1..1	uri	URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS
version	Σ	0..1	string	Version of the system - if relevant
code	ΣC	1..1	code	Código del tipo de informe/información ÚNICAS
display	ΣC	1..1	string	Descripción del tipo de informe/información ÚNICAS
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level.
subject	Σ	1..1	Reference(Patient Paciente ÚNICAS)	Referencia al paciente
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR. Identificador de la referencia del recurso FHIR asociado cuando exista/creamos un recurso en el mismo servidor FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Tipos de documentos de identificación para persona ÚNICAS Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Additional Bindings Purpose Documentation Value set de Tipos de documentos de identificación para persona ÚNICAS Extensible
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	Code defined by a terminology system
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	Σ	0..1	uri	URL del SNOMED CT. Extensión para España del SNS
version	Σ	0..1	string	Version of the system - if relevant
code	ΣC	0..1	code	Código del identificador
display	ΣC	0..1	string	Decripción del identificador
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
system	Σ	0..1	uri	OID registro de número de CIP-SNS Example General: urn:oid:2.16.724.4.40
value	ΣC	0..1	string	Número CIP-SNS Example General: BBBBBBBBQR648597
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Nombre completo del paciente
context	C	0..*	Reference(Encounter Interacción Clínica ÚNICAS)	Referencia a la interacción clínica
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	0..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	0..1	Identifier	Identificador del recurso FHIR
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	Sistema para identificar el origen Example General: urn:regcess:0123456789
value	ΣC	0..1	string	Identificador interno del sistema para la interacción clínica Example General: 123456
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Text alternative for the resource
event		0..*	CodeableReference()	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
bodySite	Σ	0..*	CodeableReference(BodyStructure)	Body part included Binding: SNOMEDCTBodyStructures (example): SNOMED CT Body site concepts
facilityType	C	0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting	C	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).
period	Σ	0..1	Period	Time of service that is being documented
date	Σ	1..1	instant	Fecha de publicación del informe/información
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam)	Who and/or what authored the document
attester		0..*	BackboneElement	Attests to accuracy of the 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
mode		1..1	CodeableConcept	personal | professional | legal | official Binding: CompositionAttestationMode (preferred): The way in which a person authenticated a document.
time		0..1	dateTime	When the document was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the document
custodian		1..1	Reference(Organization Institución ÚNICAS)	Referencia a la institución
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Referencia recurso FHIR
type	Σ	1..1	uri	Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	ΣC	1..1	Identifier	Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS
id		0..1	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
use	?!Σ	0..1	code	usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
type	Σ	0..1	CodeableConcept	Description of identifier Binding: IdentifierTypeCodes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
system	Σ	0..1	uri	OID registro de número de REGCESS Example General: urn:oid:2.16.724.4.21.5.10
value	ΣC	0..1	string	Código REGCESS Example General: 0123456789
period	Σ	0..1	Period	Time period when id is/was valid for use
assigner	Σ	0..1	Reference(Organization)	Organization that issued id (may be just text)
display	ΣC	0..1	string	Nombre completo de la institución
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	CodeableConcept	The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	1..1	markdown	Título del informe/información ÚNICAS
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System.
content	Σ	1..*	BackboneElement	Contenido del documento codificado en Base64, que puede incluir formatos como PDF o HL7 CDA
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	id	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	ΣC	0..1	code	Tipo de datos (application/pdf | multipart/x-hl7-cda-level-one) Binding: MimeTypes (required): BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) Example General: text/plain; charset=UTF-8, image/png
language	Σ	0..1	code	Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language. Additional Bindings Purpose CommonLanguages Starter Example General: en-AU
data	C	0..1	base64Binary	Datos en base64 (Debe indicar un HL7 CDA o un PDF convertido a datos base64)
url	Σ	1..1	url	URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	integer64	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	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
height		0..1	positiveInt	Height of the image in pixels (photo/video)
width		0..1	positiveInt	Width of the image in pixels (photo/video)
frames		0..1	positiveInt	Number of frames if > 1 (photo)
duration		0..1	decimal	Length in seconds (audio / video)
pages		0..1	positiveInt	Number of printed pages
profile	Σ	0..*	BackboneElement	Content profile rules for the 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
value[x]	Σ	1..1		Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (preferred): Document Format Codes.
valueCoding			Coding
valueUri			uri
valueCanonical			canonical(Any)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|5.0.0 From the FHIR Standard
DocumentReference.docStatus	required	CompositionStatus http://hl7.org/fhir/ValueSet/composition-status|5.0.0 From the FHIR Standard
DocumentReference.modality	extensible	​Modality (missing link) http://dicom.nema.org/medical/dicom/current/output/chtml/part16/sect_CID_33.html From this IG
DocumentReference.type	preferred	ValuesetTiposInformesUNICAS https://unicas-fhir.sanidad.gob.es/ValueSet/TiposInformesUNICAS From this IG
DocumentReference.category	example	ReferencedItemCategoryValueSet http://hl7.org/fhir/ValueSet/referenced-item-category From the FHIR Standard
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.subject.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.subject.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.context.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.context.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.context.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.bodySite	example	SNOMEDCTBodyStructures http://hl7.org/fhir/ValueSet/body-site From the FHIR Standard
DocumentReference.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.attester.mode	preferred	CompositionAttestationMode http://hl7.org/fhir/ValueSet/composition-attestation-mode From the FHIR Standard
DocumentReference.custodian.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.custodian.identifier.use	required	IdentifierUse http://hl7.org/fhir/ValueSet/identifier-use|5.0.0 From the FHIR Standard
DocumentReference.custodian.identifier.type	extensible	IdentifierTypeCodes http://hl7.org/fhir/ValueSet/identifier-type From the FHIR Standard
DocumentReference.relatesTo.code	extensible	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type From the FHIR Standard
DocumentReference.securityLabel	example	SecurityLabelExamples http://hl7.org/fhir/ValueSet/security-label-examples From the FHIR Standard
DocumentReference.content.attachment.contentType	required	MimeTypes(a valid code from urn:ietf:bcp:13) http://hl7.org/fhir/ValueSet/mimetypes|5.0.0 From the FHIR Standard
DocumentReference.content.attachment.language	required	AllLanguages http://hl7.org/fhir/ValueSet/all-languages|5.0.0 From the FHIR Standard
DocumentReference.content.profile.value[x]	preferred	HL7FormatCodes http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

Id	Grade	Path(s)	Details	Requirements
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().ofType(canonical) | %resource.descendants().ofType(uri) | %resource.descendants().ofType(url))) or descendants().where(reference = '#').exists() or descendants().where(ofType(canonical) = '#').exists() or descendants().where(ofType(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()
docRef-1	warning	DocumentReference	facilityType SHALL only be present if context is not an encounter : facilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2	warning	DocumentReference	practiceSetting SHALL only be present if context is not present : practiceSetting.empty() or context.where(resolve() is Encounter).empty()
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()
regcess-system	warning	DocumentReference.identifier.system	system debe comenzar por urn:regcess: seguido del identificador del sistema. : matches('^urn:regcess:[A-Za-z0-9]+$')

This structure is derived from DocumentReference

Summary

Mandatory: 13 elements(3 nested mandatory elements)

Structures

This structure refers to these other structures:

• Patient Paciente ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASPatient)
• Encounter Interacción Clínica ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASEncounter)
• Organization Institución ÚNICAS (https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASOrganization)