US Behavioral Health Profiles Implementation Guide
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US Behavioral Health Profiles Implementation Guide - Downloaded Version 0.1.0 See the Directory of published versions

## Resource Profile: Mental Health Clinical Notes Profile ( Experimental )

Official URL: http://fhir.org/guides/astp/bhp/StructureDefinition/mental-health-clinical-notes | Version: 0.1.0
Active as of 2025-08-18 | Computable Name: MentalHealthClinicalNotes

Usages:

- Examples for this Profile: DocumentReference/mental-health-consult-note-example-1, DocumentReference/mental-health-discharge-summary-example-1, DocumentReference/mental-health-hx-physical-example-1, DocumentReference/mental-health-procedure-example-1 and DocumentReference/mental-health-progress-example-1

You can also check for usages in the FHIR IG Statistics

### Formal Views of Profile Content

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

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

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | 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
identifier | S Σ | 0..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore | Σ | 0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document Binding: USCoreDocumentReferenceCategory (7.0.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0) S | Practitioner | Group | Device) | Who/what is the subject of the document
date | S Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(US Core Practitioner Profile(7.0.0) S | US Core Organization Profile(7.0.0) | US Core Patient Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0) | Device) | Who and/or what authored the document
content | S Σ | 1..* | BackboneElement | Document referenced
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | Where to access the document Constraints: us-core-6
contentType | S Σ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data | S C | 0..1 | base64Binary | Data inline, base64ed
url | S Σ C | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format | S Σ | 0..1 | Coding | Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
context | S Σ | 0..1 | BackboneElement | Clinical context of document
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Context of the document content
period | S Σ | 0..1 | Period | Time of service that is being documented
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status` From the FHIR Standard
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category|7.0.0`
DocumentReference.content.attachment.contentType | required | Mime Types(a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` From the FHIR Standard
DocumentReference.content.format | extensible | HL7FormatCodes `http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes|2.1.0`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |

This structure is derived from USCoreDocumentReferenceProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | A reference to a document
type |  | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | 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
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 | S Σ | 0..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore | Σ | 0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document Binding: USCoreDocumentReferenceCategory (7.0.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0) S | Practitioner | Group | Device) | Who/what is the subject of the document
date | S Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(US Core Practitioner Profile(7.0.0) S | US Core Organization Profile(7.0.0) | US Core Patient Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0) | Device) | Who and/or what authored the document
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
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 | Σ | 0..1 | string | Human-readable description
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..* | BackboneElement | Document referenced
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 | S Σ C | 1..1 | Attachment | Where to access the document Constraints: us-core-6
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 | S Σ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | S C | 0..1 | base64Binary | Data inline, base64ed
url | S Σ C | 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 | S Σ | 0..1 | Coding | Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
context | S Σ | 0..1 | BackboneElement | Clinical context of document
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Context of the document content
event |  | 0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
period | S Σ | 0..1 | Period | Time of service that is being documented
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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status` From the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category|7.0.0`
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` From the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` From the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types(a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` From the FHIR Standard
DocumentReference.content.attachment.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.content.format | extensible | HL7FormatCodes `http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes|2.1.0`
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode|3.0.0`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` From the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |

This structure is derived from USCoreDocumentReferenceProfile

Summary

Key Elements View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | 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
identifier | S Σ | 0..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore | Σ | 0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document Binding: USCoreDocumentReferenceCategory (7.0.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0) S | Practitioner | Group | Device) | Who/what is the subject of the document
date | S Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(US Core Practitioner Profile(7.0.0) S | US Core Organization Profile(7.0.0) | US Core Patient Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0) | Device) | Who and/or what authored the document
content | S Σ | 1..* | BackboneElement | Document referenced
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
attachment | S Σ C | 1..1 | Attachment | Where to access the document Constraints: us-core-6
contentType | S Σ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
data | S C | 0..1 | base64Binary | Data inline, base64ed
url | S Σ C | 0..1 | url | Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format | S Σ | 0..1 | Coding | Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
context | S Σ | 0..1 | BackboneElement | Clinical context of document
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Context of the document content
period | S Σ | 0..1 | Period | Time of service that is being documented
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status` From the FHIR Standard
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category|7.0.0`
DocumentReference.content.attachment.contentType | required | Mime Types(a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` From the FHIR Standard
DocumentReference.content.format | extensible | HL7FormatCodes `http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes|2.1.0`

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |

Differential View

This structure is derived from USCoreDocumentReferenceProfile

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | A reference to a document
type |  | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Documentation for this format

#### Terminology Bindings (Differential)

Path | Conformance | ValueSet | URI
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG

Snapshot View

Name | Flags | Card. | Type | Description & Constraints Filter: Bindings Constraints Obligations
--- | --- | --- | --- | ---
DocumentReference |  | 0..* | USCoreDocumentReferenceProfile(7.0.0) | 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
language |  | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
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 | S Σ | 0..* | Identifier | Other identifiers for the document
status | ?!S Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type | S Σ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: Mental Health Clinical Note Types (required)
Slices for category | S Σ | 1..* | CodeableConcept | Categorization of document Slice: Unordered, Open by pattern:$this Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
category:uscore | Σ | 0..* | CodeableConcept | 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document Binding: USCoreDocumentReferenceCategory (7.0.0) (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets
subject | S Σ | 1..1 | Reference(US Core Patient Profile(7.0.0) S | Practitioner | Group | Device) | Who/what is the subject of the document
date | S Σ | 0..1 | instant | When this document reference was created
author | S Σ | 0..* | Reference(US Core Practitioner Profile(7.0.0) S | US Core Organization Profile(7.0.0) | US Core Patient Profile(7.0.0) | US Core PractitionerRole Profile(7.0.0) | US Core RelatedPerson Profile(7.0.0) | Device) | Who and/or what authored the document
authenticator |  | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document
custodian |  | 0..1 | Reference(Organization) | Organization which maintains the document
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 | Σ | 0..1 | string | Human-readable description
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content | S Σ | 1..* | BackboneElement | Document referenced
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 | S Σ C | 1..1 | Attachment | Where to access the document Constraints: us-core-6
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 | S Σ | 0..1 | code | Mime type of the content, with charset etc. Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language | Σ | 0..1 | code | Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language.
Additional Bindings | Purpose
AllLanguages | Max Binding
Example General: en-AU
data | S C | 0..1 | base64Binary | Data inline, base64ed
url | S Σ C | 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 | S Σ | 0..1 | Coding | Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
context | S Σ | 0..1 | BackboneElement | Clinical context of document
id |  | 0..1 | string | Unique id for inter-element referencing
extension |  | 0..* | Extension | Additional content defined by implementations
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized
encounter | S | 0..1 | Reference(US Core Encounter Profile(7.0.0)) | Context of the document content
event |  | 0..* | CodeableConcept | Main clinical acts documented Binding: ActCode (3.0.0) (example): This list of codes represents the main clinical acts being documented.
period | S Σ | 0..1 | Period | Time of service that is being documented
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
Documentation for this format

#### Terminology Bindings

Path | Conformance | ValueSet | URI
DocumentReference.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.status | required | DocumentReferenceStatus `http://hl7.org/fhir/ValueSet/document-reference-status` From the FHIR Standard
DocumentReference.docStatus | required | CompositionStatus `http://hl7.org/fhir/ValueSet/composition-status|4.0.1` From the FHIR Standard
DocumentReference.type | required | MentalHealthClinicalNoteTypes `http://fhir.org/guides/astp/bhp/ValueSet/mental-health-clinical-note-types` From this IG
DocumentReference.category | example | DocumentClassValueSet `http://hl7.org/fhir/ValueSet/document-classcodes` From the FHIR Standard
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory `http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category|7.0.0`
DocumentReference.relatesTo.code | required | DocumentRelationshipType `http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1` From the FHIR Standard
DocumentReference.securityLabel | extensible | All Security Labels `http://hl7.org/fhir/ValueSet/security-labels` From the FHIR Standard
DocumentReference.content.attachment.contentType | required | Mime Types(a valid code from `urn:ietf:bcp:13`) `http://hl7.org/fhir/ValueSet/mimetypes|4.0.1` From the FHIR Standard
DocumentReference.content.attachment.language | preferred | CommonLanguages `http://hl7.org/fhir/ValueSet/languages` From the FHIR Standard
Additional Bindings | Purpose
AllLanguages | Max Binding
DocumentReference.content.format | extensible | HL7FormatCodes `http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes|2.1.0`
DocumentReference.context.event | example | ActCode `http://terminology.hl7.org/ValueSet/v3-ActCode|3.0.0`
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSet `http://hl7.org/fhir/ValueSet/c80-facilitycodes` From the FHIR Standard
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSet `http://hl7.org/fhir/ValueSet/c80-practice-codes` From the FHIR Standard

#### Constraints

Id | Grade | Path(s) | Details | Requirements
dom-2 | error | DocumentReference | If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty() |
dom-3 | error | DocumentReference | If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().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() |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |

This structure is derived from USCoreDocumentReferenceProfile

Summary

Other representations of profile: CSV, Excel, Schematron