Release 5 Preview #2

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

Documentreference-example.json

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw JSON (canonical form + also see JSON Format Specification)

Generic example

{
  "resourceType": "DocumentReference",
  "id": "example",
  "text": {
    "status": "generated",
    "div": "<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><p><b>author</b>: </p><ul><li><a>Practitioner/xcda1</a></li><li>id: a2; Gerald Smitty </li></ul><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 --&gt; 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>"
  },
  "contained": [
    {
      "resourceType": "Practitioner",
      "id": "a2",
      "name": [
        {
          "family": "Smitty",
          "given": [
            "Gerald"
          ]
        }
      ]
    }
  ],
  "masterIdentifier": {
    "system": "urn:ietf:rfc:3986",
    "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7"
  },
  "identifier": [
    {
      "system": "urn:ietf:rfc:3986",
      "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"
    }
  ],
  "status": "current",
  "docStatus": "preliminary",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34108-1",
        "display": "Outpatient Note"
      }
    ]
  },
  "category": [
    {
      "coding": [
        {
          "system": "http://ihe.net/xds/connectathon/classCodes",
          "code": "History and Physical",
          "display": "History and Physical"
        }
      ]
    }
  ],
  "subject": {
    "reference": "Patient/xcda"
  },
  "date": "2005-12-24T09:43:41+11:00",
  "author": [
    {
      "reference": "Practitioner/xcda1"
    },
    {
      "reference": "#a2"
    }
  ],
  "authenticator": {
    "reference": "Organization/f001"
  },
  "custodian": {
    "reference": "Organization/f001"
  },
  "relatesTo": [
    {
      "code": "appends",
      "target": {
        "reference": "DocumentReference/example"
      }
    }
  ],
  "description": "Physical",
  "securityLabel": [
    {
      "coding": [
        {
          "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
          "code": "V",
          "display": "very restricted"
        }
      ]
    }
  ],
  "content": [
    {
      "attachment": {
        "contentType": "application/hl7-v3+xml",
        "language": "en-US",
        "url": "http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510",
        "size": "3654",
        "hash": "2jmj7l5rSw0yVb/vlWAYkK/YBwk=",
        "title": "Physical",
        "creation": "2005-12-24T09:35:00+11:00"
      },
      "format": {
        "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
        "code": "urn:ihe:pcc:handp:2008",
        "display": "History and Physical Specification"
      }
    }
  ],
  "context": {
    "encounter": [
      {
        "reference": "Encounter/xcda"
      }
    ],
    "event": [
      {
        "coding": [
          {
            "system": "http://ihe.net/xds/connectathon/eventCodes",
            "code": "T-D8200",
            "display": "Arm"
          }
        ]
      }
    ],
    "period": {
      "start": "2004-12-23T08:00:00+11:00",
      "end": "2004-12-23T08:01:00+11:00"
    },
    "facilityType": {
      "coding": [
        {
          "system": "http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes",
          "code": "Outpatient",
          "display": "Outpatient"
        }
      ]
    },
    "practiceSetting": {
      "coding": [
        {
          "system": "http://www.ihe.net/xds/connectathon/practiceSettingCodes",
          "code": "General Medicine",
          "display": "General Medicine"
        }
      ]
    },
    "sourcePatientInfo": {
      "reference": "Patient/xcda"
    },
    "related": [
      {
        "reference": "Patient/xcda",
        "identifier": {
          "system": "urn:ietf:rfc:3986",
          "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"
        }
      }
    ]
  }
}

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.