DSTU2 QA Preview

This page is part of the FHIR Specification (v1.0.0: DSTU 2 Ballot 3). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

6.9 Resource DocumentReference - Content

Structured Documents Work GroupMaturity Level: 2Compartments: Device, Patient, Practitioner, RelatedPerson

A reference to a document.

6.9.1 Scope and Usage

A document reference resource is used to describe a document that is made available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g. what subject, author etc), can be displayed to the user, and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type, and that conforms to this definition.

Typically, Document Reference Resources are used in document indexing systems, such as IHE XDS (see the XDS specific profile), and are used to refer to:

  • CDA documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents , and even digital records of faxes where sufficient information is available
  • Other kinds of documents, such as records of prescriptions.

6.9.2 Boundaries and Relationships

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. This resource is mainly intended for general references to other documents.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource, or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet, or a DICOM exchange, or a v2 message query, though the way each of these service calls works must be specified in some external standard or other documentation.

A DocumentReference describes some other document. This means that there are two sets of provenance information relevant here: the provenance of the document, and the provenance of the document reference. Sometimes, the provenance information is closely related, as when the document producer also produces the DocumentReference, but in other workflows, the document reference is generated later by other actors. In the DocumentReference resource, the meta content refers to the provenance of the reference itself, while the content described below concerns the document it references. Like all resources, there is overlap between the information in the resource directly, and in the general Provenance resource. This is discussed as part of the description of the Provenance resource.

This resource is referenced by Contract and DiagnosticOrder

6.9.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference ΣDomainResourceA reference to a document
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... subject Σ0..1Reference(Patient | Practitioner | Group | Device)Who|what is the subject of the document
... type Σ1..1CodeableConceptKind of document (LOINC if possible)
Document Type Value Set (Preferred)
... class Σ0..1CodeableConceptCategorization of document
Document Class Value Set (Example)
... author Σ0..*Reference(Practitioner | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... custodian Σ0..1Reference(Organization)Org which maintains the document
... authenticator Σ0..1Reference(Practitioner | Organization)Who/What authenticated the document
... created Σ0..1dateTimeDocument creation time
... indexed Σ1..1instantWhen this document reference created
... status ?! Σ1..1codecurrent | superseded | entered-in-error
DocumentReferenceStatus (Required)
... docStatus Σ0..1CodeableConceptpreliminary | final | appended | amended | entered-in-error
CompositionStatus (Required)
... relatesTo ?! Σ0..*BackboneElementRelationships to other documents
.... code Σ1..1codereplaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
All Security Labels (Extensible)
... content Σ1..*BackboneElementDocument referenced
.... attachment Σ1..1AttachmentWhere to access the document
.... format Σ0..*CodingFormat/content rules for the document
DocumentReference Format Code Set (Preferred)
... context Σ0..1BackboneElementClinical context of document
.... encounter Σ0..1Reference(Encounter)Context of the document content
.... event Σ0..*CodeableConceptMain Clinical Acts Documented
v3 Code System ActCode (Example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Facililty Type Code Value Set (Example)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Practice Setting Code Value Set (Example)
.... sourcePatientInfo Σ0..1Reference(Patient)Patient demographics from source
.... related Σ0..*BackboneElementRelated identifiers or resources
..... identifier Σ0..1IdentifierIdentifer of related objects or events
..... ref Σ0..1Reference(Any)Related Resource

doco Documentation for this format

UML Diagram

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier [0..1]Other identifiers associated with the document, including version independent identifiersidentifier : Identifier [0..*]Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (I.e. machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference [0..1] « Patient|Practitioner|Group|Device »Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referencedtype : CodeableConcept [1..1] « Precice type of clinical document (Strength=Preferred)Document Type Value Set? »A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.typeclass : CodeableConcept [0..1] « High-level kind of a clinical document at a macro level (Strength=Example)Document Class Value Set?? »Identifies who is responsible for adding the information to the documentauthor : Reference [0..*] « Practitioner|Organization|Device|Patient| RelatedPerson »Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference [0..1] « Organization »Which person or organization authenticates that this document is validauthenticator : Reference [0..1] « Practitioner|Organization »When the document was createdcreated : dateTime [0..1]When the document reference was createdindexed : instant [1..1]The status of this document reference (this element modifies the meaning of other elements)status : code [1..1] « The status of the document reference (Strength=Required)DocumentReferenceStatus! »The status of the underlying documentdocStatus : CodeableConcept [0..1] « Status of the underlying document (Strength=Required)CompositionStatus! »Human-readable description of the source document. This is sometimes known as the "title"description : string [0..1]A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security is the security labels of the reference to the document, while DocumentReference.securityLabel is the security labels on the document it refers tosecurityLabel : CodeableConcept [0..*] « Security Labels from the Healthcare Privacy and Security Classification System (Strength=Extensible)All Security Labels+ »RelatesToThe type of relationship that this document has with anther documentcode : code [1..1] « The type of relationship between documents (Strength=Required)DocumentRelationshipType! »The target document of this relationshiptarget : Reference [1..1] « DocumentReference »ContentThe document or url to the document along with critical metadata to prove content has integrityattachment : Attachment [1..1]An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : Coding [0..*] « Document Format Codes (Strength=Preferred)DocumentReference Format Code...? »ContextDescribes the clinical encounter or type of care that the document content is associated withencounter : Reference [0..1] « Encounter »This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept [0..*] « This list of codes represents the main clinical acts being documented (Strength=Example)v3 Code System ActCode?? »The time period over which the service that is described by the document was providedperiod : Period [0..1]The kind of facility where the patient was seenfacilityType : CodeableConcept [0..1] « XDS Facility Type (Strength=Example)Facililty Type Code Value Set?? »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept [0..1] « Additional details about where the content was created (e.g. clinical specialty) (Strength=Example)Practice Setting Code Value S...?? »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference [0..1] « Patient »RelatedRelated identifier to this DocumentReference. If both id and ref are present they shall refer to the same thingidentifier : Identifier [0..1]Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thingref : Reference [0..1] « Any »Relationships that this document has with other document references that already exist (this element modifies the meaning of other elements)relatesTo[0..*]The document and format referenced. May be multiple content each with a different formatcontent[1..*]Related identifiers or resources associated with the DocumentReferencerelated[0..*]The clinical context in which the document was preparedcontext[0..1]

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 0..1 Reference(Patient|Practitioner|Group|Device) Who|what is the subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <class><!-- 0..1 CodeableConcept Categorization of document --></class>
 <author><!-- 0..* Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) Who and/or what authored the document --></author>
 <custodian><!-- 0..1 Reference(Organization) Org which maintains the document --></custodian>
 <authenticator><!-- 0..1 Reference(Practitioner|Organization) Who/What authenticated the document --></authenticator>
 <created value="[dateTime]"/><!-- 0..1 Document creation time -->
 <indexed value="[instant]"/><!-- 1..1 When this document reference created -->
 <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error -->
 <docStatus><!-- 0..1 CodeableConcept preliminary | final | appended | amended | entered-in-error --></docStatus>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends -->
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[string]"/><!-- 0..1 Human-readable description (title) -->
 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>
 <content>  <!-- 1..* Document referenced -->
  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <format><!-- 0..* Coding Format/content rules for the document --></format>
 </content>
 <context>  <!-- 0..1 Clinical context of document -->
  <encounter><!-- 0..1 Reference(Encounter) Context of the document  content --></encounter>
  <event><!-- 0..* CodeableConcept Main Clinical Acts Documented --></event>
  <period><!-- 0..1 Period Time of service that is being documented --></period>
  <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
  <practiceSetting><!-- 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
  <sourcePatientInfo><!-- 0..1 Reference(Patient) Patient demographics from source --></sourcePatientInfo>
  <related>  <!-- 0..* Related identifiers or resources -->
   <identifier><!-- 0..1 Identifier Identifer of related objects or events --></identifier>
   <ref><!-- 0..1 Reference(Any) Related Resource --></ref>
  </related>
 </context>
</DocumentReference>

JSON Template

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "masterIdentifier" : { Identifier }, // Master Version Specific Identifier
  "identifier" : [{ Identifier }], // Other identifiers for the document
  "subject" : { Reference(Patient|Practitioner|Group|Device) }, // Who|what is the subject of the document
  "type" : { CodeableConcept }, // R!  Kind of document (LOINC if possible)
  "class" : { CodeableConcept }, // Categorization of document
  "author" : [{ Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) }], // Who and/or what authored the document
  "custodian" : { Reference(Organization) }, // Org which maintains the document
  "authenticator" : { Reference(Practitioner|Organization) }, // Who/What authenticated the document
  "created" : "<dateTime>", // Document creation time
  "indexed" : "<instant>", // R!  When this document reference created
  "status" : "<code>", // R!  current | superseded | entered-in-error
  "docStatus" : { CodeableConcept }, // preliminary | final | appended | amended | entered-in-error
  "relatesTo" : [{ // Relationships to other documents
    "code" : "<code>", // R!  replaces | transforms | signs | appends
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<string>", // Human-readable description (title)
  "securityLabel" : [{ CodeableConcept }], // Document security-tags
  "content" : [{ // R!  Document referenced
    "attachment" : { Attachment }, // R!  Where to access the document
    "format" : [{ Coding }] // Format/content rules for the document
  }],
  "context" : { // Clinical context of document
    "encounter" : { Reference(Encounter) }, // Context of the document  content
    "event" : [{ CodeableConcept }], // Main Clinical Acts Documented
    "period" : { Period }, // Time of service that is being documented
    "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
    "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
    "sourcePatientInfo" : { Reference(Patient) }, // Patient demographics from source
    "related" : [{ // Related identifiers or resources
      "identifier" : { Identifier }, // Identifer of related objects or events
      "ref" : { Reference(Any) } // Related Resource
    }]
  }
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference ΣDomainResourceA reference to a document
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier Σ0..*IdentifierOther identifiers for the document
... subject Σ0..1Reference(Patient | Practitioner | Group | Device)Who|what is the subject of the document
... type Σ1..1CodeableConceptKind of document (LOINC if possible)
Document Type Value Set (Preferred)
... class Σ0..1CodeableConceptCategorization of document
Document Class Value Set (Example)
... author Σ0..*Reference(Practitioner | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... custodian Σ0..1Reference(Organization)Org which maintains the document
... authenticator Σ0..1Reference(Practitioner | Organization)Who/What authenticated the document
... created Σ0..1dateTimeDocument creation time
... indexed Σ1..1instantWhen this document reference created
... status ?! Σ1..1codecurrent | superseded | entered-in-error
DocumentReferenceStatus (Required)
... docStatus Σ0..1CodeableConceptpreliminary | final | appended | amended | entered-in-error
CompositionStatus (Required)
... relatesTo ?! Σ0..*BackboneElementRelationships to other documents
.... code Σ1..1codereplaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description (title)
... securityLabel Σ0..*CodeableConceptDocument security-tags
All Security Labels (Extensible)
... content Σ1..*BackboneElementDocument referenced
.... attachment Σ1..1AttachmentWhere to access the document
.... format Σ0..*CodingFormat/content rules for the document
DocumentReference Format Code Set (Preferred)
... context Σ0..1BackboneElementClinical context of document
.... encounter Σ0..1Reference(Encounter)Context of the document content
.... event Σ0..*CodeableConceptMain Clinical Acts Documented
v3 Code System ActCode (Example)
.... period Σ0..1PeriodTime of service that is being documented
.... facilityType Σ0..1CodeableConceptKind of facility where patient was seen
Facililty Type Code Value Set (Example)
.... practiceSetting Σ0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Practice Setting Code Value Set (Example)
.... sourcePatientInfo Σ0..1Reference(Patient)Patient demographics from source
.... related Σ0..*BackboneElementRelated identifiers or resources
..... identifier Σ0..1IdentifierIdentifer of related objects or events
..... ref Σ0..1Reference(Any)Related Resource

doco Documentation for this format

UML Diagram

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier [0..1]Other identifiers associated with the document, including version independent identifiersidentifier : Identifier [0..*]Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (I.e. machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference [0..1] « Patient|Practitioner|Group|Device »Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referencedtype : CodeableConcept [1..1] « Precice type of clinical document (Strength=Preferred)Document Type Value Set? »A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.typeclass : CodeableConcept [0..1] « High-level kind of a clinical document at a macro level (Strength=Example)Document Class Value Set?? »Identifies who is responsible for adding the information to the documentauthor : Reference [0..*] « Practitioner|Organization|Device|Patient| RelatedPerson »Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference [0..1] « Organization »Which person or organization authenticates that this document is validauthenticator : Reference [0..1] « Practitioner|Organization »When the document was createdcreated : dateTime [0..1]When the document reference was createdindexed : instant [1..1]The status of this document reference (this element modifies the meaning of other elements)status : code [1..1] « The status of the document reference (Strength=Required)DocumentReferenceStatus! »The status of the underlying documentdocStatus : CodeableConcept [0..1] « Status of the underlying document (Strength=Required)CompositionStatus! »Human-readable description of the source document. This is sometimes known as the "title"description : string [0..1]A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security is the security labels of the reference to the document, while DocumentReference.securityLabel is the security labels on the document it refers tosecurityLabel : CodeableConcept [0..*] « Security Labels from the Healthcare Privacy and Security Classification System (Strength=Extensible)All Security Labels+ »RelatesToThe type of relationship that this document has with anther documentcode : code [1..1] « The type of relationship between documents (Strength=Required)DocumentRelationshipType! »The target document of this relationshiptarget : Reference [1..1] « DocumentReference »ContentThe document or url to the document along with critical metadata to prove content has integrityattachment : Attachment [1..1]An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : Coding [0..*] « Document Format Codes (Strength=Preferred)DocumentReference Format Code...? »ContextDescribes the clinical encounter or type of care that the document content is associated withencounter : Reference [0..1] « Encounter »This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept [0..*] « This list of codes represents the main clinical acts being documented (Strength=Example)v3 Code System ActCode?? »The time period over which the service that is described by the document was providedperiod : Period [0..1]The kind of facility where the patient was seenfacilityType : CodeableConcept [0..1] « XDS Facility Type (Strength=Example)Facililty Type Code Value Set?? »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept [0..1] « Additional details about where the content was created (e.g. clinical specialty) (Strength=Example)Practice Setting Code Value S...?? »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference [0..1] « Patient »RelatedRelated identifier to this DocumentReference. If both id and ref are present they shall refer to the same thingidentifier : Identifier [0..1]Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thingref : Reference [0..1] « Any »Relationships that this document has with other document references that already exist (this element modifies the meaning of other elements)relatesTo[0..*]The document and format referenced. May be multiple content each with a different formatcontent[1..*]Related identifiers or resources associated with the DocumentReferencerelated[0..*]The clinical context in which the document was preparedcontext[0..1]

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 0..1 Reference(Patient|Practitioner|Group|Device) Who|what is the subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <class><!-- 0..1 CodeableConcept Categorization of document --></class>
 <author><!-- 0..* Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) Who and/or what authored the document --></author>
 <custodian><!-- 0..1 Reference(Organization) Org which maintains the document --></custodian>
 <authenticator><!-- 0..1 Reference(Practitioner|Organization) Who/What authenticated the document --></authenticator>
 <created value="[dateTime]"/><!-- 0..1 Document creation time -->
 <indexed value="[instant]"/><!-- 1..1 When this document reference created -->
 <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error -->
 <docStatus><!-- 0..1 CodeableConcept preliminary | final | appended | amended | entered-in-error --></docStatus>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends -->
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[string]"/><!-- 0..1 Human-readable description (title) -->
 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>
 <content>  <!-- 1..* Document referenced -->
  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <format><!-- 0..* Coding Format/content rules for the document --></format>
 </content>
 <context>  <!-- 0..1 Clinical context of document -->
  <encounter><!-- 0..1 Reference(Encounter) Context of the document  content --></encounter>
  <event><!-- 0..* CodeableConcept Main Clinical Acts Documented --></event>
  <period><!-- 0..1 Period Time of service that is being documented --></period>
  <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
  <practiceSetting><!-- 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
  <sourcePatientInfo><!-- 0..1 Reference(Patient) Patient demographics from source --></sourcePatientInfo>
  <related>  <!-- 0..* Related identifiers or resources -->
   <identifier><!-- 0..1 Identifier Identifer of related objects or events --></identifier>
   <ref><!-- 0..1 Reference(Any) Related Resource --></ref>
  </related>
 </context>
</DocumentReference>

JSON Template

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "masterIdentifier" : { Identifier }, // Master Version Specific Identifier
  "identifier" : [{ Identifier }], // Other identifiers for the document
  "subject" : { Reference(Patient|Practitioner|Group|Device) }, // Who|what is the subject of the document
  "type" : { CodeableConcept }, // R!  Kind of document (LOINC if possible)
  "class" : { CodeableConcept }, // Categorization of document
  "author" : [{ Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) }], // Who and/or what authored the document
  "custodian" : { Reference(Organization) }, // Org which maintains the document
  "authenticator" : { Reference(Practitioner|Organization) }, // Who/What authenticated the document
  "created" : "<dateTime>", // Document creation time
  "indexed" : "<instant>", // R!  When this document reference created
  "status" : "<code>", // R!  current | superseded | entered-in-error
  "docStatus" : { CodeableConcept }, // preliminary | final | appended | amended | entered-in-error
  "relatesTo" : [{ // Relationships to other documents
    "code" : "<code>", // R!  replaces | transforms | signs | appends
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<string>", // Human-readable description (title)
  "securityLabel" : [{ CodeableConcept }], // Document security-tags
  "content" : [{ // R!  Document referenced
    "attachment" : { Attachment }, // R!  Where to access the document
    "format" : [{ Coding }] // Format/content rules for the document
  }],
  "context" : { // Clinical context of document
    "encounter" : { Reference(Encounter) }, // Context of the document  content
    "event" : [{ CodeableConcept }], // Main Clinical Acts Documented
    "period" : { Period }, // Time of service that is being documented
    "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
    "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
    "sourcePatientInfo" : { Reference(Patient) }, // Patient demographics from source
    "related" : [{ // Related identifiers or resources
      "identifier" : { Identifier }, // Identifer of related objects or events
      "ref" : { Reference(Any) } // Related Resource
    }]
  }
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON), Questionnaire

6.9.3.1 Terminology Bindings

PathDefinitionTypeReference
DocumentReference.type Precice type of clinical documentPreferredDocument Type Value Set
DocumentReference.class High-level kind of a clinical document at a macro levelExampleDocument Class Value Set
DocumentReference.status The status of the document referenceRequiredDocumentReferenceStatus
DocumentReference.docStatus Status of the underlying documentRequiredCompositionStatus
DocumentReference.relatesTo.code The type of relationship between documentsRequiredDocumentRelationshipType
DocumentReference.securityLabel Security Labels from the Healthcare Privacy and Security Classification SystemExtensibleAll Security Labels
DocumentReference.content.format Document Format CodesPreferredDocumentReference Format Code Set
DocumentReference.context.event This list of codes represents the main clinical acts being documentedExamplev3 Code System ActCode
DocumentReference.context.facilityType XDS Facility TypeExampleFacililty Type Code Value Set
DocumentReference.context.practiceSetting Additional details about where the content was created (e.g. clinical specialty)ExamplePractice Setting Code Value Set

6.9.4 Implementation Notes

  • The use of the .docStatus codes is discussed in the Composition description
  • The resources maintain one way relationships that point backwards - e.g. the document that replaces one document points towards the document that it replaced. The reverse relationships can be followed by using indexes built from the resources. Typically, this is done using the search parameters described below. Given that documents may have other documents that replace or append them, clients should always check these relationships when accessing documents

6.9.4.1 Generating a Document Reference

A client can ask a server to generate a document reference from a document. The server reads the existing document and generates a matching DocumentReference resource, or returns one it has previously generated. Servers may be able to return or generate document references for the following types of content:

Type Comments
FHIR Documents The uri refers to an existing Document
CDA Document The uri is a reference to a Binary end-point that returns either a CDA document, or some kind of CDA Package that the server knows how to process (e.g. an IHE .zip)
Other The server can be asked to generate a document reference for other kinds of documents. For some of these documents (e.g. PDF documents) a server could only provide a DocumentReference it is already existed, or the server had special knowledge of the document

The server either returns a search result containing a single DocumentReference, or it returns an error. If some the URI refers to another server, it is at the discretion of the server whether to retrieve it or return an error.

The operation is initiated by a named query, using _query=generate on the /DocumentReference end point: 

  GET [service-url]/DocumentReference/?_query=generate&uri=:url&...

The "uri" parameter is a relative or absolute reference to one of the document types described above. Other parameters may be supplied:

Name Meaning
persist Whether to store the document at the document end-point (/Document) or not once it is generated. Value = true or false (default is for the server to decide)

6.9.5 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
authenticatorreferenceWho/What authenticated the documentDocumentReference.authenticator
(Organization, Practitioner)
authorreferenceWho and/or what authored the documentDocumentReference.author
(Device, Patient, Organization, Practitioner, RelatedPerson)
classtokenCategorization of documentDocumentReference.class
createddateDocument creation timeDocumentReference.created
custodianreferenceOrg which maintains the documentDocumentReference.custodian
(Organization)
descriptionstringHuman-readable description (title)DocumentReference.description
encounterreferenceContext of the document contentDocumentReference.context.encounter
(Encounter)
eventtokenMain Clinical Acts DocumentedDocumentReference.context.event
facilitytokenKind of facility where patient was seenDocumentReference.context.facilityType
formattokenFormat/content rules for the documentDocumentReference.content.format
identifiertokenMaster Version Specific IdentifierDocumentReference.masterIdentifier, DocumentReference.identifier
indexeddateWhen this document reference createdDocumentReference.indexed
languagetokenHuman language of the content (BCP-47)DocumentReference.content.attachment.language
locationuriUri where the data can be foundDocumentReference.content.attachment.url
patientreferenceWho|what is the subject of the documentDocumentReference.subject
(Patient)
perioddateTime of service that is being documentedDocumentReference.context.period
related-idtokenIdentifer of related objects or eventsDocumentReference.context.related.identifier
related-refreferenceRelated ResourceDocumentReference.context.related.ref
(Any)
relatestoreferenceTarget of the relationshipDocumentReference.relatesTo.target
(DocumentReference)
relationtokenreplaces | transforms | signs | appendsDocumentReference.relatesTo.code
relationshipcompositeCombination of relation and relatesTo
securitylabeltokenDocument security-tagsDocumentReference.securityLabel
settingtokenAdditional details about where the content was created (e.g. clinical specialty)DocumentReference.context.practiceSetting
statustokencurrent | superseded | entered-in-errorDocumentReference.status
subjectreferenceWho|what is the subject of the documentDocumentReference.subject
(Device, Patient, Practitioner, Group)
typetokenKind of document (LOINC if possible)DocumentReference.type