This page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). 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
Structured Documents Work Group | Maturity Level: N/A | Ballot Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw XML (canonical form + also see XML Format Specification)
Generic example (id = "example")
<?xml version="1.0" encoding="UTF-8"?> <DocumentReference xmlns="http://hl7.org/fhir"> <id value="example"/> <!-- Many XDS systems do not trak any id for the author. When systems don't do this, the only option is for the author information to be contained in the Document Reference --> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative with Details</b> </p> <p> <b> id</b> : example</p> <p> <b> contained</b> : </p> <p> <b> masterIdentifier</b> : urn:oid:1.3.6.1.4.1.21367.2005.3.7</p> <p> <b> identifier</b> : urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p> <p> <b> status</b> : current</p> <p> <b> docStatus</b> : preliminary</p> <p> <b> type</b> : Outpatient Note <span> (Details : {LOINC code '34108-1' = 'Outpatient Note', given as 'Outpatient Note'})</span> </p> <p> <b> category</b> : History and Physical <span> (Details : {http://ihe.net/xds/connectathon/classCodes code 'History and Physical' = 'History and Physical', given as 'History and Physical'})</span> </p> <p> <b> subject</b> : <a> Patient/xcda</a> </p> <p> <b> date</b> : 24/12/2005 9:43:41 AM</p> <blockquote> <p> <b> agent</b> </p> <p> <b> type</b> : author (originator) <span> (Details : {http://terminology.hl7.org/CodeSystem/v3-ParticipationType code 'AUT' = 'author (originator)', given as 'author (originator)'})</span> </p> <p> <b> who</b> : <a> Practitioner/xcda1</a> </p> </blockquote> <blockquote> <p> <b> agent</b> </p> <p> <b> type</b> : author (originator) <span> (Details : {http://terminology.hl7.org/CodeSystem/v3-ParticipationType code 'AUT' = 'author (originator)', given as 'author (originator)'})</span> </p> <p> <b> who</b> : id: a2; Gerald Smitty </p> </blockquote> <p> <b> authenticator</b> : <a> Organization/f001</a> </p> <p> <b> custodian</b> : <a> Organization/f001</a> </p> <h3> RelatesTos</h3> <table> <tr> <td> -</td> <td> <b> Code</b> </td> <td> <b> Target</b> </td> </tr> <tr> <td> *</td> <td> appends</td> <td> <a> DocumentReference/example</a> </td> </tr> </table> <p> <b> description</b> : Physical</p> <p> <b> securityLabel</b> : very restricted <span> (Details : {http://terminology.hl7.org/CodeSystem/v3-Confidentiality code 'V' = 'very restricted', given as 'very restricted'})</span> </p> <h3> Contents</h3> <table> <tr> <td> -</td> <td> <b> Attachment</b> </td> <td> <b> Format</b> </td> </tr> <tr> <td> *</td> <td/> <td> History and Physical Specification (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:ihe:pcc:handp: 2008 = 'urn:ihe:pcc:handp:2008', stated as 'History and Physical Specification')</td> </tr> </table> <h3> Contexts</h3> <table> <tr> <td> -</td> <td> <b> Encounter</b> </td> <td> <b> Event</b> </td> <td> <b> Period</b> </td> <td> <b> FacilityType</b> </td> <td> <b> PracticeSetting</b> </td> <td> <b> SourcePatientInfo</b> </td> <td> <b> Related</b> </td> </tr> <tr> <td> *</td> <td> <a> Encounter/xcda</a> </td> <td> Arm <span> (Details : {http://ihe.net/xds/connectathon/eventCodes code 'T-D8200' = 'T-D8200', given as 'Arm'})</span> </td> <td> 23/12/2004 8:00:00 AM --> 23/12/2004 8:01:00 AM</td> <td> Outpatient <span> (Details : {http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes code 'Outpatient' = 'Outpatient', given as 'Outpatient'})</span> </td> <td> General Medicine <span> (Details : {http://www.ihe.net/xds/connectathon/practiceSettingCodes code 'General Medicine' = 'General Medicine', given as 'General Medicine'})</span> </td> <td> <a> Patient/xcda</a> </td> <td> <a> Patient/xcda</a> </td> </tr> </table> </div> </text> <contained> <Practitioner> <id value="a2"/> <name> <family value="Smitty"/> <given value="Gerald"/> </name> </Practitioner> </contained> <masterIdentifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7"/> </masterIdentifier> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"/> </identifier> <status value="current"/> <docStatus value="preliminary"/> <type> <coding> <system value="http://loinc.org"/> <code value="34108-1"/> <display value="Outpatient Note"/> </coding> </type> <category> <coding> <system value="http://ihe.net/xds/connectathon/classCodes"/> <code value="History and Physical"/> <display value="History and Physical"/> </coding> </category> <subject> <reference value="Patient/xcda"/> </subject> <date value="2005-12-24T09:43:41+11:00"/> <agent> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/> <code value="AUT"/> <display value="author (originator)"/> </coding> </type> <who> <reference value="Practitioner/xcda1"/> </who> </agent> <agent> <type> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-ParticipationType"/> <code value="AUT"/> <display value="author (originator)"/> </coding> </type> <who> <reference value="#a2"/> </who> </agent> <authenticator> <reference value="Organization/f001"/> </authenticator> <custodian> <reference value="Organization/f001"/> </custodian> <relatesTo> <code value="appends"/> <target> <reference value="DocumentReference/example"/> </target> </relatesTo> <description value="Physical"/> <securityLabel> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/> <code value="V"/> <display value="very restricted"/> </coding> </securityLabel> <content> <attachment> <contentType value="application/hl7-v3+xml"/> <language value="en-US"/> <url value="http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510"/> <size value="3654"/> <hash value="2jmj7l5rSw0yVb/vlWAYkK/YBwk="/> <title value="Physical"/> <creation value="2005-12-24T09:35:00+11:00"/> </attachment> <format> <system value="urn:oid:1.3.6.1.4.1.19376.1.2.3"/> <code value="urn:ihe:pcc:handp:2008"/> <display value="History and Physical Specification"/> </format> </content> <context> <encounter> <reference value="Encounter/xcda"/> </encounter> <event> <coding> <system value="http://ihe.net/xds/connectathon/eventCodes"/> <code value="T-D8200"/> <display value="Arm"/> </coding> </event> <period> <start value="2004-12-23T08:00:00+11:00"/> <end value="2004-12-23T08:01:00+11:00"/> </period> <facilityType> <coding> <system value="http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes"/> <code value="Outpatient"/> <display value="Outpatient"/> </coding> </facilityType> <practiceSetting> <coding> <system value="http://www.ihe.net/xds/connectathon/practiceSettingCodes"/> <code value="General Medicine"/> <display value="General Medicine"/> </coding> </practiceSetting> <sourcePatientInfo> <reference value="Patient/xcda"/> </sourcePatientInfo> <related> <reference value="Patient/xcda"/> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"/> </identifier> </related> </context> </DocumentReference>
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.