Health NZ | Te Whatu Ora FHIR Screening Implementation Guide - Local Development build (v0.9.2) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

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Resource Profile: ScreeningSummaryDocument

A FHIR DocumentReference representation of a screening summary report

Usage:

• Examples for this Resource Profile: DocumentReference/CervicalScreeningSummary-DeceasedWithScreeningHistory, DocumentReference/CervicalScreeningSummary-ParticipantOnly, DocumentReference/CervicalScreeningSummary, DocumentReference/CervicalScreeningSummaryPDF and DocumentReference/DocumentReferenceExample1

Formal Views of Profile Content

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

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

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules		0..0
language		0..0
text		0..0
contained		0..0
extension		0..0
modifierExtension		0..0
docStatus		0..0
type		0..1	CodeableConcept	All screening summary DocRefs have this type code Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
category		0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject		0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date		0..1	instant	The 'as-at' date (UTC) of the screening summary report
author		0..*	Reference(Organization)	Who and/or what authored the document
authenticator		0..0
relatesTo		0..0
description		0..0
securityLabel		0..0
content		1..*	BackboneElement	Attaches a rendition of the screening summary report
extension		0..0
modifierExtension		0..0
attachment
data		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
creation		0..1	dateTime	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	0..1	CodeableConcept	All screening summary DocRefs have this type code Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
category	Σ	0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject	Σ	0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date	Σ	0..1	instant	The 'as-at' date (UTC) of the screening summary report
author	Σ	0..*	Reference(Organization)	Who and/or what authored the document
content	Σ	1..*	BackboneElement	Attaches a rendition of the screening summary report
attachment	Σ	1..1	Attachment	Where to access the document
data		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
creation	Σ	0..1	dateTime	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	Pattern: SNOMED-CT Code 422735006("Summary clinical document (record artifact)") http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard

Name	Flags	Card.	Type	Description & Constraints
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
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	0..1	CodeableConcept	All screening summary DocRefs have this type code Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject	Σ	0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date	Σ	0..1	instant	The 'as-at' date (UTC) of the screening summary report
author	Σ	0..*	Reference(Organization)	Who and/or what authored the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
content	Σ	1..*	BackboneElement	Attaches a rendition of the screening summary report
id		0..1	string	Unique id for inter-element referencing
attachment	Σ	1..1	Attachment	Where to access the document
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	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		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
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	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	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		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
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	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 / Code	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	Pattern: SNOMED-CT Code 422735006("Summary clinical document (record artifact)") http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
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

This structure is derived from DocumentReference

Summary

Prohibited: 13 elements

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules		0..0
language		0..0
text		0..0
contained		0..0
extension		0..0
modifierExtension		0..0
docStatus		0..0
type		0..1	CodeableConcept	All screening summary DocRefs have this type code Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
category		0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject		0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date		0..1	instant	The 'as-at' date (UTC) of the screening summary report
author		0..*	Reference(Organization)	Who and/or what authored the document
authenticator		0..0
relatesTo		0..0
description		0..0
securityLabel		0..0
content		1..*	BackboneElement	Attaches a rendition of the screening summary report
extension		0..0
modifierExtension		0..0
attachment
data		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
creation		0..1	dateTime	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	0..1	CodeableConcept	All screening summary DocRefs have this type code Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
category	Σ	0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject	Σ	0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date	Σ	0..1	instant	The 'as-at' date (UTC) of the screening summary report
author	Σ	0..*	Reference(Organization)	Who and/or what authored the document
content	Σ	1..*	BackboneElement	Attaches a rendition of the screening summary report
attachment	Σ	1..1	Attachment	Where to access the document
data		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
creation	Σ	0..1	dateTime	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	Pattern: SNOMED-CT Code 422735006("Summary clinical document (record artifact)") http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
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
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	Σ	0..*	Identifier	Other identifiers for the document
status	?!Σ	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference.
type	Σ	0..1	CodeableConcept	All screening summary DocRefs have this type code Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 422735006
display		1..1	string	Representation defined by the system Fixed Value: Summary clinical document (record artifact)
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
category	Σ	0..*	CodeableConcept	In screening summary DocRefs, denotes the type of screening programme only; cannot be used for other categorization purposes Binding: Codes for categorization of NZ types of screening programme (required)
subject	Σ	0..1	Reference(Patient)	Identifies the patient by an NHI identifier (a FHIR logical reference), AND a local Patient instance (a literal reference)
date	Σ	0..1	instant	The 'as-at' date (UTC) of the screening summary report
author	Σ	0..*	Reference(Organization)	Who and/or what authored the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
content	Σ	1..*	BackboneElement	Attaches a rendition of the screening summary report
id		0..1	string	Unique id for inter-element referencing
attachment	Σ	1..1	Attachment	Where to access the document
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	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		0..1	base64Binary	Screening summary document inlined as base64 content. By default this is an HTML rendition.
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	The dateTime (UTC) the screening summary content was generated if different from the report 'as-at' date
format	Σ	0..1	Coding	Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes.
context	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		0..*	Reference(Encounter | EpisodeOfCare)	Context of the document content
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	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 / Code	URI
DocumentReference.status	required	DocumentReferenceStatus http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard
DocumentReference.type	preferred	Pattern: SNOMED-CT Code 422735006("Summary clinical document (record artifact)") http://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard
DocumentReference.category	required	NzScreeningProgrammeTypesVS https://fhir-ig-uat.digital.health.nz/fhir-screening/ValueSet/nz-screening-programmetype-code from this IG
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 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 Additional Bindings Purpose AllLanguages Max Binding http://hl7.org/fhir/ValueSet/languages from the FHIR Standard
DocumentReference.content.format	preferred	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem) http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
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

This structure is derived from DocumentReference

Summary

Prohibited: 13 elements

Other representations of profile: CSV, Excel, Schematron