This page is part of the FHIR Specification (v0.01: Historical Archive Draft). The current version which supercedes this version is 4.0.1. For a full list of available versions, see the Directory of published versions

# Document

A documentation of clinical observations and services that are aggregated together into a single statement of clinical meaning that establishes it's own context. A clinical document is composed of a set of resources that include both human and computer readable portions. A human must attest to the accuracy of the human readable portion, and may authenticate and/or sign the entire whole.

The relative url is /documents

## Content

    <Document xmlns="http://www.hl7.org/fhir">
      <id> mand id Master Resource Id = document Id</id>
      <instant> mand instant Document Creation Time</instant>
      <type> mand CodeableConcept Document Type (LOINC if possible)</type>
      <title> opt string Document Title</title>
      <setId> cond id Id fixed across all document revisions</setId>
      <version> opt integer used to version successive replacement documents</version>
      <replaces> cond id If this document replaces another</replaces>
      <subject> mand (Patient|Group) who the document is about</subject>
      <author> mand  <!-- One+ Author (contributed content to document) -->
       <time> opt dateTime When authoring happened</time>
       <party> mand (Person|Device) who/what authored the final document</party>
      </author>
      <attestor> opt  <!-- Zero+ attests to accuracy of document -->
       <mode> mand code personal | professional | legal | official</mode>
       <time> opt dateTime When document attested</time>
       <party> opt (Person|Organisation) who attested the document</party>
      </attestor>
      <recipient> opt Zero+ (Person|Organization) expected to receive a copy </recipient>
      <custodian> mand (Organization) org which maintains the document.</custodian>
      <event> opt (Any) the clinical item being documented</event>
      <encounter> opt (Admission|InterestOfCare) context of the document</encounter>
      <section> mand  <!-- One+ Document is broken into sections -->
       <type> opt CodeableConcept type of section (recommended)</type>
       <instant> opt instant Section Creation Time</instant>
       <author> opt  <!-- if section author different to document -->
        <time> opt dateTime When authoring happened</time>
        <party> mand (Person|Device) who/what authored the section</party>
       </author>
       <enterer> opt (Person|Device) The source of the data entry</enterer>
       <subject> opt (Person|Group) if section different to document</subject>
       <informant> opt (Person) provided information in section</informant>
       <content> cond (Any) the actual content of the section</content>
       <section> cond  <!-- Zero+ nested Section -->
         <!-- Content as for Document.Section -->
       </section>
      </section>
      <extensions> opt See Extensions   See Extensions </extensions>
      <text> mand Narrative Text summary of message, for human interpretation</text>
    </Document>

Schema for Document and an example (or formatted for browser)

Terminology Bindings

- Document.type is bound to the concept domain DocumentType: "Type of a clinical document". If an appropriate code exists in LOINC then it should be used
- Document.attestor.mode is bound to the concept domain DocumentAuthenticationMode: "The way in which a person authenticated a document". Possible values:

  personal | The person authenticated the document in their personal capacity
  professional | The person authenticated the document in their professional capacity
  legal | The person authenticated the document and accepted legal responsibility for it's content
  official | The organization authenticated the document as consistent with their policies and procedures

- Document.section.type is bound to the concept domain DocumentSectionType: "Type of a clinical document section". If an appropriate code exists in LOINC then it should be used

Notes:

- The Document resource can be used in a RESTful framework as a stand-alone resource, or as the basis for a full document in the document framework.
- The author and the attestor are often the same person, but this may not be the case in many clinical workflows
- The attestor attests to the collated narrative portions of the resources
- The author, subject, enterer, and informant features are inherited in contained sections, and need not be repeated. Specifying any of these in a section replaces the inherited value
- The custodian is responsible for the maintainance of the document. Principally, they are responsible for the policy regarding persistence of the documents. They need not actually retain a copy of the document, but they should do so.

## Displaying a document

The human display of the Document is the collated narrative portions of following resources (in order):

1. The Document itself
2. The subject resource
3. Resources referenced in the section.content

The document narrative should summarise the important parts of the document header that are required to establish clinical context for the document (other than the subject, which is displayed in it's own right). To actually build the combined narrative, simply append all the narratives xhtml fragments. The viewer program can provide it's own stylesheet (.css) for the combined html of the narrative, but cannot change any styles specified internally in the existing narratives.

### Originator Responsibilities

A document originator is an application that creates a document resource. The originator may create new content resources or assemble already existing content resources while doing so. A document originator has the following responsibilities:

- Build a document that conforms to the Document rules, and links to content resources that also conform to the rules for the resources
- Ensure that the content of the document is frozen and easily reproducible, either by aggregating the document, or using version specific resource references in a FHIR conformant RESTful framework
- Ensure that the content of the documend and other resources conforms to any applicable conformance statements and declared clinical patterns.

### Recipient Responsibilities

A document recipient is an application that receives documents from a document originator or document management system. The document recipient is responsible for ensuring that received CDA documents are processed and/or rendered in accordance to this specification. A document recipient has the following responsibilities:

- Assume default values where they are defined in the FHIR specification (see the list here)
- Render the document following the rules described above
- A recipient is allowed to extract resources or data from the document, but doing so voids the attestation, and the recipient should always ensure that the user can access the original document when displaying extracted data
- Warn users when a superceded document is displayed, and either withdraw data extracted from superceded documents, or warn users when they view it

## Formal Definitions

The formal definitions for the elements above. Also available as an XML file.

Document
Definition | A documentation of clinical observations and services that are aggregated together into a single statement of clinical meaning that establishes it's own context. A clinical document is composed of a set of resources that include both human and computer readable portions. A human must attest to the accuracy of the human readable portion, and may authenticate and/or sign the entire whole
Control | Mandatory, 1..1
Must Understand | true
Requirements | For document based framework
To Do | Confidentiality? Language? Consent? Signatures
Document.id
Definition | the unique id of a clinical document
Control | Mandatory, 1..1
Type | id
Must Understand | true
Requirements | Each document needs a unique identifier so other documents and underlying infrastructure can reference it
Comments | must be globally unique. UUIDs are recommended
Document.instant
Definition | the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created.
Control | Mandatory, 1..1
Type | instant
Must Understand | true
Document.type
Definition | specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note)
Control | Mandatory, 1..1
Type | CodeableConcept from DocumentType
Must Understand | true
Document.title
Definition | the title of the document
Control | Optional, 0..1
Type | string
Comments | It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of Document.type (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the Document.title value should be used
Document.setId
Definition | Represents an identifier that is common across all document revisions
Control | Conditional, 0..1: cannot have both setId and replaces
Type | id
Must Understand | true
Document.version
Definition | used to version successive replacement documents
Control | Optional, 0..1
Type | integer
Must Understand | true
Comments | An integer value is recommended
Document.replaces
Definition | If this document replaces another
Control | Conditional, 0..1: cannot have both setId and replaces
Type | id
Must Understand | true
Document.subject
Definition | who the document is about
Control | Mandatory, 1..1
Type | Resource(Patient|Group)
Must Understand | true
Document.author
Definition | Author (contributed content to document)
Control | Mandatory, 1..*
Document.author.time
Definition | When authoring happened
Control | Optional, 0..1
Type | dateTime
Document.author.party
Definition | who/what authored the final document
Control | Mandatory, 1..1
Type | Resource(Person|Device)
Document.attestor
Definition | a participant who has attested to the accuracy of the document
Control | Optional, 0..*
Document.attestor.mode
Definition | The type of attestation the authenticator offers
Control | Mandatory, 1..1
Type | code from DocumentAuthenticationMode
Document.attestor.time
Definition | When document attested
Control | Optional, 0..1
Type | dateTime
Document.attestor.party
Definition | who attested the document
Control | Optional, 0..1
Type | Resource(Person|Organisation)
Document.recipient
Definition | expected to receive a copy
Control | Optional, 0..*
Type | Resource(Person|Organization)
Document.custodian
Definition | org which maintains the document.
Control | Mandatory, 1..1
Type | Resource(Organization)
Document.event
Definition | the main Act, such as a colonoscopy or an appendectomy, being documented
Control | Optional, 0..1
Type | Resource(Any)
Comments | The event needs to be consistent with the type element, though can provide further information if desired
Document.encounter
Definition | context of the document
Control | Optional, 0..1
Type | Resource(Admission|InterestOfCare)
Document.section
Definition | Document is broken into sections
Control | Mandatory, 1..*
Document.section.type
Definition | type of section (recommended)
Control | Optional, 0..1
Type | CodeableConcept from DocumentSectionType
Document.section.instant
Definition | the section creation time (sections are often re-used in several documents).
Control | Optional, 0..1
Type | instant
Document.section.author
Definition | if section author different to document
Control | Optional, 0..1
Document.section.author.time
Definition | When authoring happened
Control | Optional, 0..1
Type | dateTime
Document.section.author.party
Definition | who/what authored the section
Control | Mandatory, 1..1
Type | Resource(Person|Device)
Document.section.enterer
Definition | The person or device that performed the data entry leading to this section. Where there is more than one candidate, pick the most proximal to the message. Can provide other enterers in extensions
Control | Optional, 0..1
Type | Resource(Person|Device)
Document.section.subject
Definition | if section different to document
Control | Optional, 0..1
Type | Resource(Person|Group)
Must Understand | true
Document.section.informant
Definition | provided information in section
Control | Optional, 0..1
Type | Resource(Person)
Document.section.content
Definition | the actual content of the section
Control | Conditional, 0..1: a section must have content or one or more sections
Type | Resource(Any)
Must Understand | true
Document.section.section
Definition | nested Section
Control | Conditional, 0..*: a section must have content or one or more sections
Document.section.section.#
Definition | contents as for a section
Control | Mandatory, 1..1
Type | @Document.Section
Document.extensions
Definition | See Extensions
Control | Optional, 0..1
Document.text
Definition |
Control | Mandatory, 1..1
Type | Narrative

This is an old version of FHIR retained for archive purposes. Do not use for anything else
Implementers are welcome to experiment with the content defined here, but should note that the contents are subject to change without prior notice.
© HL7.org 2011 - 2012. FHIR v0.01 generated on Mon, May 14, 2012 09:48+1000.