This page is part of the FHIR Specification (v4.4.0: R5 Preview #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
Orders and Observations Work Group | Maturity Level: 3 | Trial Use | Security Category: Not Classified | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Detailed Descriptions for the elements in the DocumentReference resource.
DocumentReference | |
Element Id | DocumentReference |
Definition | A reference to a document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference. |
Cardinality | 0..* |
Type | DomainResource |
Comments | Usually, this is used for documents other than those defined by FHIR. |
DocumentReference.masterIdentifier | |
Element Id | DocumentReference.masterIdentifier |
Definition | 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 document. |
Cardinality | 0..1 |
Type | Identifier |
Requirements | The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.). |
Summary | true |
Comments | CDA Document Id extension and root. |
DocumentReference.identifier | |
Element Id | DocumentReference.identifier |
Definition | Other identifiers associated with the document, including version independent identifiers. |
Note | This is a business identifier, not a resource identifier (see discussion) |
Cardinality | 0..* |
Type | Identifier |
Summary | true |
DocumentReference.status | |
Element Id | DocumentReference.status |
Definition | The status of this document reference. |
Cardinality | 1..1 |
Terminology Binding | DocumentReferenceStatus (Required) |
Type | code |
Is Modifier | true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid) |
Summary | true |
Comments | This is the status of the DocumentReference object, which might be independent from the docStatus element. This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid. |
DocumentReference.docStatus | |
Element Id | DocumentReference.docStatus |
Definition | The status of the underlying document. |
Cardinality | 0..1 |
Terminology Binding | CompositionStatus (Required) |
Type | code |
Summary | true |
Comments | The document that is pointed to might be in various lifecycle states. |
DocumentReference.type | |
Element Id | DocumentReference.type |
Definition | 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 referenced. |
Cardinality | 0..1 |
Terminology Binding | Document Type Value Set (Preferred) |
Type | CodeableConcept |
Summary | true |
Comments | Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents. |
DocumentReference.category | |
Element Id | DocumentReference.category |
Definition | 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.type. |
Cardinality | 0..* |
Terminology Binding | Document Class Value Set (Example) |
Type | CodeableConcept |
Alternate Names | class |
Summary | true |
Comments | Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching. |
DocumentReference.subject | |
Element Id | DocumentReference.subject |
Definition | Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a 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). |
Cardinality | 0..1 |
Type | Reference(Patient | Practitioner | Group | Device | PractitionerRole | Specimen | Organization | Location) |
Patterns | Reference(Patient,Practitioner,Group,Device,PractitionerRole,Specimen,Organization,Location): No common pattern |
Summary | true |
DocumentReference.date | |
Element Id | DocumentReference.date |
Definition | When the document reference was created. |
Cardinality | 0..1 |
Type | instant |
Alternate Names | indexed |
Summary | true |
Comments | Referencing/indexing time is used for tracking, organizing versions and searching. |
DocumentReference.author | |
Element Id | DocumentReference.author |
Definition | Identifies who is responsible for adding the information to the document. |
Cardinality | 0..* |
Type | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam) |
Patterns | Reference(Practitioner,PractitionerRole,Organization,Device,Patient,RelatedPerson,CareTeam): Common patterns = Participant |
Summary | true |
Comments | Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). |
DocumentReference.authenticator | |
Element Id | DocumentReference.authenticator |
Definition | Which person or organization authenticates that this document is valid. |
Cardinality | 0..1 |
Type | Reference(Practitioner | PractitionerRole | Organization) |
Patterns | Reference(Practitioner,PractitionerRole,Organization): Common patterns = Participant |
Comments | Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator. |
DocumentReference.custodian | |
Element Id | DocumentReference.custodian |
Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the document. |
Cardinality | 0..1 |
Type | Reference(Organization) |
Comments | Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization. |
DocumentReference.relatesTo | |
Element Id | DocumentReference.relatesTo |
Definition | Relationships that this document has with other document references that already exist. |
Cardinality | 0..* |
Summary | true |
Comments | This element is labeled as a modifier because documents that append to other documents are incomplete on their own. |
DocumentReference.relatesTo.code | |
Element Id | DocumentReference.relatesTo.code |
Definition | The type of relationship that this document has with anther document. |
Cardinality | 1..1 |
Terminology Binding | DocumentRelationshipType (Required) |
Type | code |
Summary | true |
Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
DocumentReference.relatesTo.target | |
Element Id | DocumentReference.relatesTo.target |
Definition | The target document of this relationship. |
Cardinality | 1..1 |
Type | Reference(DocumentReference) |
Summary | true |
DocumentReference.description | |
Element Id | DocumentReference.description |
Definition | Human-readable description of the source document. |
Cardinality | 0..1 |
Type | string |
Requirements | Helps humans to assess whether the document is of interest. |
Summary | true |
Comments | What the document is about, a terse summary of the document. |
DocumentReference.securityLabel | |
Element Id | DocumentReference.securityLabel |
Definition | A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to. |
Cardinality | 0..* |
Terminology Binding | SecurityLabels (Extensible) |
Type | CodeableConcept |
Requirements | Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. |
Summary | true |
Comments | The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects. |
DocumentReference.content | |
Element Id | DocumentReference.content |
Definition | The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata. |
Cardinality | 1..* |
Summary | true |
Comments | Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats. |
DocumentReference.content.attachment | |
Element Id | DocumentReference.content.attachment |
Definition | The document or URL of the document along with critical metadata to prove content has integrity. |
Cardinality | 1..1 |
Type | Attachment |
Summary | true |
DocumentReference.content.format | |
Element Id | DocumentReference.content.format |
Definition | An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. |
Cardinality | 0..1 |
Terminology Binding | DocumentReference Format Code Set (Preferred) |
Type | Coding |
Summary | true |
Comments | Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. |
DocumentReference.context | |
Element Id | DocumentReference.context |
Definition | The clinical context in which the document was prepared. |
Cardinality | 0..1 |
Summary | true |
Comments | These values are primarily added to help with searching for interesting/relevant documents. |
DocumentReference.context.encounter | |
Element Id | DocumentReference.context.encounter |
Definition | Describes the clinical encounter or type of care that the document content is associated with. |
Cardinality | 0..* |
Type | Reference(Encounter) |
DocumentReference.context.event | |
Element Id | DocumentReference.context.event |
Definition | 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 type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. |
Cardinality | 0..* |
Terminology Binding | v3 Code System ActCode (Example) |
Type | CodeableConcept |
Comments | An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation. |
DocumentReference.context.period | |
Element Id | DocumentReference.context.period |
Definition | The time period over which the service that is described by the document was provided. |
Cardinality | 0..1 |
Type | Period |
Summary | true |
DocumentReference.context.facilityType | |
Element Id | DocumentReference.context.facilityType |
Definition | The kind of facility where the patient was seen. |
Cardinality | 0..1 |
Terminology Binding | Facility Type Code Value Set (Example) |
Type | CodeableConcept |
DocumentReference.context.practiceSetting | |
Element Id | DocumentReference.context.practiceSetting |
Definition | This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. |
Cardinality | 0..1 |
Terminology Binding | Practice Setting Code Value Set (Example) |
Type | CodeableConcept |
Requirements | This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. |
Comments | This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. |
DocumentReference.context.sourcePatientInfo | |
Element Id | DocumentReference.context.sourcePatientInfo |
Definition | The Patient Information as known when the document was published. May be a reference to a version specific, or contained. |
Cardinality | 0..1 |
Type | Reference(Patient) |
DocumentReference.context.related | |
Element Id | DocumentReference.context.related |
Definition | Related identifiers or resources associated with the DocumentReference. |
Cardinality | 0..* |
Type | Reference(Any) |
Comments | May be identifiers or resources that caused the DocumentReference or referenced Document to be created. |
DocumentReference.context.basedOn | |
Element Id | DocumentReference.context.basedOn |
Definition | A procedure that is fulfilled in whole or in part by the creation of this media. |
Cardinality | 0..* |
Type | Reference(ServiceRequest | CarePlan) |
Patterns | Reference(ServiceRequest,CarePlan): Common patterns = Request |
Requirements | Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon. |
Alternate Names | fulfills |