VN Core FHIR Implementation Guide — Bộ Hướng dẫn Triển khai FHIR Cốt lõi cho Việt Nam
0.1.0 - STU1 Draft Viet Nam flag

VN Core FHIR Implementation Guide — Bộ Hướng dẫn Triển khai FHIR Cốt lõi cho Việt Nam - Local Development build (v0.1.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Resource Profile: Tài liệu y tế VN Core — VN Core DocumentReference Profile

Official URL: http://fhir.hl7.org.vn/core/StructureDefinition/vn-core-document-reference Version: 0.1.0
Draft as of 2026-03-20 Computable Name: VNCoreDocumentReference

Profile DocumentReference cho Việt Nam. Dùng cho tham chiếu bệnh án điện tử, phiếu kết quả xét nghiệm, phim ảnh CĐHA, đơn thuốc điện tử, giấy chuyển viện, v.v. Căn cứ:

  • TT 13/2025/TT-BYT (06/6/2025) — Bệnh án điện tử, hiệu lực 21/7/2025
  • Luật KCB 2023 (15/2023/QH15) — Hồ sơ bệnh án
  • NĐ 137/2024/NĐ-CP — Giao dịch điện tử, chữ ký số
  • QĐ 1332/QĐ-BYT — Sổ sức khỏe điện tử trên VNeID
  • Luật 91/2025/QH15 — BVDLCN: dữ liệu y tế = DLCN nhạy cảm

Usages:

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.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.
... category SΣ 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... date SΣ 0..1 instant Thời điểm tạo tài liệu
... author SΣ 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... description SΣ 0..1 string Mô tả nội dung tài liệu
... content SΣ 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... contentType SΣ 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
... context SΣ 0..1 BackboneElement Ngữ cảnh lâm sàng
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... period Σ 0..1 Period Thời gian hiệu lực tài liệu

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.

Constraints

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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
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()

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... status S 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
... type S 1..1 CodeableConcept Loại tài liệu y tế
... category S 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
... date S 0..1 instant Thời điểm tạo tài liệu
... author S 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... description S 0..1 string Mô tả nội dung tài liệu
... content S 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... attachment S 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... contentType S 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
... context S 0..1 BackboneElement Ngữ cảnh lâm sàng
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... period 0..1 Period Thời gian hiệu lực tài liệu

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... 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
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Loại tài liệu y tế
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... date SΣ 0..1 instant Thời điểm tạo tài liệu
... author SΣ 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description SΣ 0..1 string Mô tả nội dung tài liệu
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... 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 SΣ 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data 0..1 base64Binary Data inline, base64ed
..... url Σ 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title Σ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
... context SΣ 0..1 BackboneElement Ngữ cảnh lâm sàng
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Thời gian hiệu lực tài liệu
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred DocumentReference Format Code Set 📍4.0.1 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.2
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

Constraints

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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
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()

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... status ?!SΣ 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.
... category SΣ 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... date SΣ 0..1 instant Thời điểm tạo tài liệu
... author SΣ 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... description SΣ 0..1 string Mô tả nội dung tài liệu
... content SΣ 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... contentType SΣ 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
... context SΣ 0..1 BackboneElement Ngữ cảnh lâm sàng
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... period Σ 0..1 Period Thời gian hiệu lực tài liệu

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.

Constraints

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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
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()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... status S 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
... type S 1..1 CodeableConcept Loại tài liệu y tế
... category S 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
... date S 0..1 instant Thời điểm tạo tài liệu
... author S 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... description S 0..1 string Mô tả nội dung tài liệu
... content S 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... attachment S 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... contentType S 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
... context S 0..1 BackboneElement Ngữ cảnh lâm sàng
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... period 0..1 Period Thời gian hiệu lực tài liệu

doco Documentation for this format

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... 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
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier Σ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code Trạng thái tài liệu (current | superseded | entered-in-error)
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Loại tài liệu y tế
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
... category SΣ 0..* CodeableConcept Phân loại tài liệu (bệnh án, XN, CĐHA, đơn thuốc...)
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
... subject SΣ 1..1 Reference(Bệnh nhân VN Core — VN Core Patient Profile) Bệnh nhân
... date SΣ 0..1 instant Thời điểm tạo tài liệu
... author SΣ 0..* Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Vai trò nhân viên y tế VN Core — VN Core PractitionerRole Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Tác giả tài liệu (bác sĩ, NVYT, CSKCB)
... authenticator 0..1 Reference(Nhân viên y tế VN Core — VN Core Practitioner Profile | Cơ sở y tế VN Core — VN Core Organization Profile) Người ký xác nhận (chữ ký số per NĐ 137/2024)
... custodian S 0..1 Reference(Cơ sở y tế VN Core — VN Core Organization Profile) Cơ sở y tế lưu trữ (per TT 13/2025)
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description SΣ 0..1 string Mô tả nội dung tài liệu
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
... content SΣ 1..* BackboneElement Nội dung tài liệu (attachment hoặc URL)
.... 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 SΣ 1..1 Attachment File đính kèm (PDF, CDA, hình ảnh DICOM, v.v.)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code MIME type (application/pdf, text/xml, image/dicom...)
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data 0..1 base64Binary Data inline, base64ed
..... url Σ 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title Σ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format Σ 0..1 Coding Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
... context SΣ 0..1 BackboneElement Ngữ cảnh lâm sàng
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..* Reference(Lượt khám/nhập viện VN Core — VN Core Encounter Profile) Lượt khám liên quan
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period Thời gian hiệu lực tài liệu
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base preferred DocumentReference Format Code Set 📍4.0.1 FHIR Std.
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v6.2
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📍4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📍4.0.1 FHIR Std.

Constraints

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().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(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()
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()

 

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