ÚNICAS Rare Diseases HL7 FHIR Implementation Guide
0.0.12 - draft
ÚNICAS Rare Diseases HL7 FHIR Implementation Guide
0.0.12 - draft
ÚNICAS Rare Diseases HL7 FHIR Implementation Guide - Local Development build (v0.0.12) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://unicas-fhir.sanidad.gob.es/StructureDefinition/UNICASDocumentReference | Version: 0.0.12 | |||
| Draft as of 2026-10-13 | Computable Name: UNICASDocumentReference | |||
Este profile define las restricciones del recurso DocumentReference para representar un documento clínico en el contexto del caso de uso de ÚNICAS.
Usages:
You can also check for usages in the FHIR IG Statistics
Description of Profiles, Differentials, Snapshots and how the different presentations work.
| Name | Flags | Card. | Type | Description & Constraints Filter:  |
|---|---|---|---|---|
  DocumentReference |
C | 0..* | DocumentReference | A reference to a document Constraints: docRef-1, docRef-2 |
  implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| contained |
0..* | Resource | Contained, inline Resources | |
 modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
  identifier |
1..* | Identifier | Identificador único | |
 use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 |
 value |
C | 1..1 | string | Identificador interno del sistema para el documento Example General: 123456 Example ÚNICAS: 123456 |
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): Value set de Tipos de informes para ÚNICAS | |
 subject |
1..1 | Reference(Patient Paciente ÚNICAS) | Referencia al paciente | |
| reference |
C | 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 Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
| identifier |
C | 1..1 | Identifier | Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| type |
0..1 | CodeableConcept | Tipos de documentos de identificación para persona ÚNICAS Binding: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona ÚNICAS | |
| system |
0..1 | uri | OID registro de número de CIP-SNS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.40 | |
| value |
C | 0..1 | string | Número CIP-SNS Example General: 123456 Example ÚNICAS: BBBBBBBBQR648597 |
| display |
C | 0..1 | string | Nombre completo del paciente |
| context |
C | 0..* | Reference(Encounter Interacción Clínica ÚNICAS) | Referencia a la interacción clínica |
| reference |
C | 0..1 | string | Referencia recurso FHIR |
| type |
0..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
 identifier |
C | 0..1 | Identifier | Identificador del recurso FHIR |
 use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
0..1 | uri | Sistema para identificar el origen Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | |
| value |
C | 0..1 | string | Identificador interno del sistema para la interacción clínica Example General: 123456 Example ÚNICAS: 123456 |
| date |
1..1 | instant | Fecha de publicación del informe/información | |
| custodian |
1..1 | Reference(Organization Institución ÚNICAS) | Referencia a la institución | |
| reference |
C | 0..1 | string | Referencia recurso FHIR |
| type |
1..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
| identifier |
C | 1..1 | Identifier | Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
0..1 | uri | OID registro de número de REGCESS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |
| value |
C | 0..1 | string | Código REGCESS Example General: 123456 Example ÚNICAS: 0123456789 |
| display |
C | 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 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| attachment |
1..1 | Attachment | Where to access the document | |
| contentType |
C | 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 |
1..1 | url | URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.subject.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.context.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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: |
|---|---|---|---|---|
| DocumentReference |
DocumentReference | |||
 identifier |
1..* | Identifier | Identificador único | |
| system |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example ÚNICAS: urn:regcess:0123456789 |
| value |
1..1 | string | Identificador interno del sistema para el documento Example ÚNICAS: 123456 | |
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): 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: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona ÚNICAS | |
| 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 Example ÚNICAS: urn:oid:2.16.724.4.40 | |
| value |
0..1 | string | Número CIP-SNS Example ÚNICAS: BBBBBBBBQR648597 | |
| 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 Example ÚNICAS: urn:regcess:0123456789 | |
| value |
0..1 | string | Identificador interno del sistema para la interacción clínica Example ÚNICAS: 123456 | |
| 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 Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |
| value |
0..1 | string | Código REGCESS Example ÚNICAS: 0123456789 | |
| 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 | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
C | 0..* | DocumentReference | A reference to a document Constraints: docRef-1, docRef-2 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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
| |||||
| 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 |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | ||||
| value |
C | 1..1 | string | Identificador interno del sistema para el documento Example General: 123456 Example ÚNICAS: 123456 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| version |
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 |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
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 |
0..* | CodeableConcept | Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance. | |||||
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): 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 |
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 |
1..1 | uri | URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
C | 1..1 | code | Código del tipo de informe/información ÚNICAS | ||||
| display |
C | 1..1 | string | Descripción del tipo de informe/información ÚNICAS | ||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level. | |||||
| subject |
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 |
C | 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 Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Tipos de documentos de identificación para persona ÚNICAS Binding: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona 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 |
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 |
0..1 | uri | URL del SNOMED CT. Extensión para España del SNS | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
C | 0..1 | code | Código del identificador | ||||
| display |
C | 0..1 | string | Decripción del identificador | ||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
0..1 | uri | OID registro de número de CIP-SNS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.40 | |||||
| value |
C | 0..1 | string | Número CIP-SNS Example General: 123456 Example ÚNICAS: BBBBBBBBQR648597 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 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 |
C | 0..1 | string | Referencia recurso FHIR | ||||
| type |
0..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
0..1 | uri | Sistema para identificar el origen Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | |||||
| value |
C | 0..1 | string | Identificador interno del sistema para la interacción clínica Example General: 123456 Example ÚNICAS: 123456 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 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 |
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 |
0..1 | Period | Time of service that is being documented | |||||
| date |
1..1 | instant | Fecha de publicación del informe/información | |||||
| author |
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 |
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 |
C | 0..1 | string | Referencia recurso FHIR | ||||
| type |
1..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
0..1 | uri | OID registro de número de REGCESS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |||||
| value |
C | 0..1 | string | Código REGCESS Example General: 123456 Example ÚNICAS: 0123456789 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 0..1 | string | Nombre completo de la institución | ||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
1..1 | markdown | Título del informe/información ÚNICAS | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
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 |
C | 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 |
0..1 | code | Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language.
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 |
1..1 | url | URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png | |||||
| size |
0..1 | integer64 | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
 value[x] |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.modality | Base | extensible | Modality (missing link) | 📦2022.4.20221006 | This IG |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.context.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.4 |
| DocumentReference.bodySite | Base | example | SNOMED CT Body Structures | 📍5.0.0 | FHIR Std. |
| DocumentReference.facilityType | Base | example | Facility Type Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.practiceSetting | Base | example | Practice Setting Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.profile.value[x] | Base | preferred | HL7 ValueSet of Format Codes for use with Document Sharing | 📦2.1.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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:
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints Filter: |
|---|---|---|---|---|
| DocumentReference |
C | 0..* | DocumentReference | A reference to a document Constraints: docRef-1, docRef-2 |
| implicitRules |
0..1 | uri | A set of rules under which this content was created | |
| contained |
0..* | Resource | Contained, inline Resources | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored | |
| identifier |
1..* | Identifier | Identificador único | |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 |
| value |
C | 1..1 | string | Identificador interno del sistema para el documento Example General: 123456 Example ÚNICAS: 123456 |
| status |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): Value set de Tipos de informes para ÚNICAS | |
| subject |
1..1 | Reference(Patient Paciente ÚNICAS) | Referencia al paciente | |
| reference |
C | 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 Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
| identifier |
C | 1..1 | Identifier | Identificador de paciente CIP-SNS. Cuando no tengamos recurso Patient, se debera informar el identificador de paciente mediante CIP-SNS |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| type |
0..1 | CodeableConcept | Tipos de documentos de identificación para persona ÚNICAS Binding: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona ÚNICAS | |
| system |
0..1 | uri | OID registro de número de CIP-SNS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.40 | |
| value |
C | 0..1 | string | Número CIP-SNS Example General: 123456 Example ÚNICAS: BBBBBBBBQR648597 |
| display |
C | 0..1 | string | Nombre completo del paciente |
| context |
C | 0..* | Reference(Encounter Interacción Clínica ÚNICAS) | Referencia a la interacción clínica |
| reference |
C | 0..1 | string | Referencia recurso FHIR |
| type |
0..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
| identifier |
C | 0..1 | Identifier | Identificador del recurso FHIR |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
0..1 | uri | Sistema para identificar el origen Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | |
| value |
C | 0..1 | string | Identificador interno del sistema para la interacción clínica Example General: 123456 Example ÚNICAS: 123456 |
| date |
1..1 | instant | Fecha de publicación del informe/información | |
| custodian |
1..1 | Reference(Organization Institución ÚNICAS) | Referencia a la institución | |
| reference |
C | 0..1 | string | Referencia recurso FHIR |
| type |
1..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |
| identifier |
C | 1..1 | Identifier | Identificador de la institución. Cuando no tengamos recurso Organization, se debera informar el identificador de institución mediante código REGCESS |
| use |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |
| system |
0..1 | uri | OID registro de número de REGCESS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |
| value |
C | 0..1 | string | Código REGCESS Example General: 123456 Example ÚNICAS: 0123456789 |
| display |
C | 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 | |
| modifierExtension |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |
| attachment |
1..1 | Attachment | Where to access the document | |
| contentType |
C | 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 |
1..1 | url | URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png | |
| Documentation for this format | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.subject.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.context.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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: |
|---|---|---|---|---|
| DocumentReference |
DocumentReference | |||
| identifier |
1..* | Identifier | Identificador único | |
| system |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example ÚNICAS: urn:regcess:0123456789 |
| value |
1..1 | string | Identificador interno del sistema para el documento Example ÚNICAS: 123456 | |
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): 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: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona ÚNICAS | |
| 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 Example ÚNICAS: urn:oid:2.16.724.4.40 | |
| value |
0..1 | string | Número CIP-SNS Example ÚNICAS: BBBBBBBBQR648597 | |
| 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 Example ÚNICAS: urn:regcess:0123456789 | |
| value |
0..1 | string | Identificador interno del sistema para la interacción clínica Example ÚNICAS: 123456 | |
| 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 Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |
| value |
0..1 | string | Código REGCESS Example ÚNICAS: 0123456789 | |
| 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 | ||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| Id | Grade | Path(s) | Description | Expression |
| 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: | ||||
|---|---|---|---|---|---|---|---|---|
| DocumentReference |
C | 0..* | DocumentReference | A reference to a document Constraints: docRef-1, docRef-2 | ||||
| id |
0..1 | id | Logical id of this artifact | |||||
| meta |
0..1 | Meta | Metadata about the resource | |||||
| implicitRules |
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
| |||||
| 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 |
0..* | Extension | Extensions that cannot be ignored | |||||
| identifier |
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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
C | 1..1 | uri | Sistema para identificar el origen Constraints: regcess-system Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | ||||
| value |
C | 1..1 | string | Identificador interno del sistema para el documento Example General: 123456 Example ÚNICAS: 123456 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| version |
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 |
1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | |||||
| docStatus |
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 |
0..* | CodeableConcept | Imaging modality used Binding: Modality (extensible): Type of acquired data in the instance. | |||||
| type |
1..1 | CodeableConcept | Tipo de informe/información ÚNICAS Binding: Value set de Tipos de informes para ÚNICAS (extensible): 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 |
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 |
1..1 | uri | URL del refset Documentos del CMDIC | URL del SNOMED CT. Extensión para España del SNS | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
C | 1..1 | code | Código del tipo de informe/información ÚNICAS | ||||
| display |
C | 1..1 | string | Descripción del tipo de informe/información ÚNICAS | ||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| category |
0..* | CodeableConcept | Categorization of document Binding: ReferencedItemCategoryValueSet (example): High-level kind of document at a macro level. | |||||
| subject |
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 |
C | 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 Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
0..1 | CodeableConcept | Tipos de documentos de identificación para persona ÚNICAS Binding: Value set de Tipos de documentos de identificación para persona ÚNICAS (extensible): Value set de Tipos de documentos de identificación para persona 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 |
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 |
0..1 | uri | URL del SNOMED CT. Extensión para España del SNS | |||||
| version |
0..1 | string | Version of the system - if relevant | |||||
| code |
C | 0..1 | code | Código del identificador | ||||
| display |
C | 0..1 | string | Decripción del identificador | ||||
| userSelected |
0..1 | boolean | If this coding was chosen directly by the user | |||||
| text |
0..1 | string | Plain text representation of the concept | |||||
| system |
0..1 | uri | OID registro de número de CIP-SNS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.40 | |||||
| value |
C | 0..1 | string | Número CIP-SNS Example General: 123456 Example ÚNICAS: BBBBBBBBQR648597 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 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 |
C | 0..1 | string | Referencia recurso FHIR | ||||
| type |
0..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
0..1 | uri | Sistema para identificar el origen Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:regcess:0123456789 | |||||
| value |
C | 0..1 | string | Identificador interno del sistema para la interacción clínica Example General: 123456 Example ÚNICAS: 123456 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 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 |
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 |
0..1 | Period | Time of service that is being documented | |||||
| date |
1..1 | instant | Fecha de publicación del informe/información | |||||
| author |
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 |
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 |
C | 0..1 | string | Referencia recurso FHIR | ||||
| type |
1..1 | uri | Tipo de recurso FHIR Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model). | |||||
| identifier |
C | 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 |
0..1 | code | usual | official | temp | secondary | old (If known) Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known . | |||||
| type |
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 |
0..1 | uri | OID registro de número de REGCESS Example General: http://www.acme.com/identifiers/patient Example ÚNICAS: urn:oid:2.16.724.4.21.5.10 | |||||
| value |
C | 0..1 | string | Código REGCESS Example General: 123456 Example ÚNICAS: 0123456789 | ||||
| period |
0..1 | Period | Time period when id is/was valid for use | |||||
| assigner |
0..1 | Reference(Organization) | Organization that issued id (may be just text) | |||||
| display |
C | 0..1 | string | Nombre completo de la institución | ||||
| relatesTo |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| code |
1..1 | CodeableConcept | The relationship type with another document Binding: DocumentRelationshipType (extensible): The type of relationship between the documents. | |||||
| target |
1..1 | Reference(DocumentReference) | Target of the relationship | |||||
| description |
1..1 | markdown | Título del informe/información ÚNICAS | |||||
| securityLabel |
0..* | CodeableConcept | Document security-tags Binding: SecurityLabelExamples (example): Example Security Labels from the Healthcare Privacy and Security Classification System. | |||||
| content |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| attachment |
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 |
C | 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 |
0..1 | code | Human language of the content (BCP-47) Binding: AllLanguages (required): IETF language tag for a human language.
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 |
1..1 | url | URL del datos en formato Base64 (recurso Binary) Example General: http://www.acme.com/logo-small.png | |||||
| size |
0..1 | integer64 | Number of bytes of content (if url provided) | |||||
| hash |
0..1 | base64Binary | Hash of the data (sha-1, base64ed) | |||||
| title |
0..1 | string | Label to display in place of the data Example General: Official Corporate Logo | |||||
| creation |
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 |
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 |
0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||
| value[x] |
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 | ||||||||
| Path | Status | Usage | ValueSet | Version | Source |
| DocumentReference.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.status | Base | required | DocumentReferenceStatus | 📍5.0.0 | FHIR Std. |
| DocumentReference.docStatus | Base | required | Composition Status | 📍5.0.0 | FHIR Std. |
| DocumentReference.modality | Base | extensible | Modality (missing link) | 📦2022.4.20221006 | This IG |
| DocumentReference.type | Base | extensible | Value set de Tipos de informes para ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.category | Base | example | Referenced Item Category Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.subject.identifier.type | Base | extensible | Value set de Tipos de documentos de identificación para persona ÚNICAS | 📦0.0.12 | This IG |
| DocumentReference.context.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.context.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.event | Base | example | v3 Code System ActCode | 📦3.0.0 | THO v7.4 |
| DocumentReference.bodySite | Base | example | SNOMED CT Body Structures | 📍5.0.0 | FHIR Std. |
| DocumentReference.facilityType | Base | example | Facility Type Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.practiceSetting | Base | example | Practice Setting Code Value Set | 📍5.0.0 | FHIR Std. |
| DocumentReference.attester.mode | Base | preferred | Composition Attestation Mode | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.type | Base | extensible | Resource Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.use | Base | required | IdentifierUse | 📍5.0.0 | FHIR Std. |
| DocumentReference.custodian.identifier.type | Base | extensible | Identifier Type Codes | 📍5.0.0 | FHIR Std. |
| DocumentReference.relatesTo.code | Base | extensible | Document Relationship Type | 📍5.0.0 | FHIR Std. |
| DocumentReference.securityLabel | Base | example | Example set of Security Labels | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.contentType | Base | required | Mime Types | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.attachment.language | Base | required | All Languages | 📍5.0.0 | FHIR Std. |
| DocumentReference.content.profile.value[x] | Base | preferred | HL7 ValueSet of Format Codes for use with Document Sharing | 📦2.1.0 | THO v7.4 |
| Id | Grade | Path(s) | Description | Expression |
| dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources |
contained.contained.empty()
|
| dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource |
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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:
Other representations of profile: CSV, Excel, Schematron
ÚNICAS está impulsado por el Consejo Interterritorial del Sistema Nacional de Salud, y financiado con fondos Next Generation de la Unión Europea, en el marco del Plan de Recuperación, Transformación y Resiliencia del Gobierno de España. El Ministerio de Sanidad ejerce la coordinación del proyecto, y Cataluña lidera la parte del desarrollo de los activos tecnológicos para su implementación.
