Release 5 Ballot

This page is part of the FHIR Specification (v5.0.0-ballot: R5 Ballot - see ballot notes). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Example DocumentReference/example-comprehensive (XML)

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

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

Jump past Narrative

XDS Comprehensive metadata (id = "example-comprehensive")

<?xml version="1.0" encoding="UTF-8"?>

<DocumentReference xmlns="http://hl7.org/fhir">
  <id value="example-comprehensive"/> 
  <meta> 
    <security> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason"/> 
      <code value="HTEST"/> 
    </security> 
  </meta> 

  <text> <status value="extensions"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative: DocumentReference</b> <a name="example-comprehensive"> </a> </p> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border:
       1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource DocumentReference &quot;example-comprehensive&quot; </p> <p style="margin-bottom: 0px">Security Labels: <span title="{http://terminology.hl7.org/CodeSystem/v3-ActReason http://terminology.hl7.org/CodeSystem/v3-
          ActReason}">http://terminology.hl7.org/CodeSystem/v3-ActReason</span> </p> </div> <p> <b> sourcepatient</b> : <a name="in-patient"> </a> </p> <blockquote> <p style="border: 1px #661aff solid; background-color: #e6e6ff; padding: 10px;"><b> Anonymous Patient</b>  (no stated gender), DoB Unknown</p> <hr/>  </blockquote> <p> <b> identifier</b> : id: urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340,
         id: urn:uuid:0c287d32-01e3-4d87-9953-9fcc9404eb21</p> <p> <b> status</b> : current</p> <p> <b> type</b> : Addendum Document <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #55107-7)</span> </p> <p> <b> category</b> : History of immunization Narrative <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://loinc.org/">LOINC</a> #11369-6)</span> </p> <p> <b> subject</b> : <a href="patient-example-xcda.html">Patient/xcda</a>  &quot;Henry LEVIN&quot;</p> <h3> Events</h3> <table class="grid"><tr> <td> -</td> <td> <b> Concept</b> </td> <td> <b> Reference</b> </td> </tr> <tr> <td> *</td> <td> account receivable <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-v3-ActCode.html">ActCode</a> #ACCTRECEIVABLE)</span> </td> <td>  </td> </tr> <tr> <td> *</td> <td>  </td> <td> <span/>  </td> </tr> </table> <p> <b> facilityType</b> : Children's hospital <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #82242000)</span> </p> <p> <b> practiceSetting</b> : Adult mental illness - speciality <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="https://browser.ihtsdotools.org/">SNOMED CT</a> #408467006)</span> </p> <p> <b> period</b> : 2020-12-31T23:50:50-05:00 --&gt; 2020-12-31T23:50:50-05:00</p> <p> <b> date</b> : 01/01/2021 3:50:50 PM</p> <p> <b> author</b> : <a name="in-author"> </a> </p> <blockquote> <p/>  <p> <a name="in-author"> </a> </p> <p> <b> telecom</b> : <a href="mailto:JohnMoehrke@gmail.com">JohnMoehrke@gmail.com</a> </p> </blockquote> <h3> Attesters</h3> <table class="grid"><tr> <td> -</td> <td> <b> Mode</b> </td> <td> <b> Party</b> </td> </tr> <tr> <td> *</td> <td> Professional <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="codesystem-composition-attestation-mode.html">CompositionAttestationMode</a> #professional)</span> </td> <td> <a name="in-author"> </a> <blockquote> <p/>  <p> <a name="in-author"> </a> </p> <p> <b> telecom</b> : <a href="mailto:JohnMoehrke@gmail.com">JohnMoehrke@gmail.com</a> </p> </blockquote> </td> </tr> </table> <h3> RelatesTos</h3> <table class="grid"><tr> <td> -</td> <td> <b> Code</b> </td> <td> <b> Target</b> </td> </tr> <tr> <td> *</td> <td> Appends <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="codesystem-document-relationship-type.html">DocumentRelationshipType</a> #appends)</span> </td> <td> <a href="documentreference-example.html">DocumentReference/example</a> </td> </tr> </table> <p> <b> description</b> : Example of a Comprehensive DocumentReference resource. This is fully filled for
         all mandatory elements and all optional elements.</p> <p> <b> securityLabel</b> : normal <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a href="http://terminology.hl7.org/3.1.0/CodeSystem-v3-Confidentiality.html">Confidentiality</a> #N)</span> </p> <blockquote> <p> <b> content</b> </p> <h3> Attachments</h3> <table class="grid"><tr> <td> -</td> <td> <b> ContentType</b> </td> <td> <b> Language</b> </td> <td> <b> Url</b> </td> <td> <b> Size</b> </td> <td> <b> Hash</b> </td> <td> <b> Title</b> </td> <td> <b> Creation</b> </td> </tr> <tr> <td> *</td> <td> text/plain</td> <td> en</td> <td> <a href="http://example.com/nowhere.txt">http://example.com/nowhere.txt</a> </td> <td> 190</td> <td> OGEzOGYyNjMzMDA2ZmQ1MzUxNDljNDRhM2E3M2YzMTI0MzdiMzQ3OA==</td> <td> DocumentReference for Comprehensive fully filled metadata</td> <td> 2020-12-31T23:50:50-05:00</td> </tr> </table> <h3> Profiles</h3> <table class="grid"><tr> <td> -</td> <td> <b> Value[x]</b> </td> </tr> <tr> <td> *</td> <td> ITI XDS-SD TEXT (Details: http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode
               code urn:ihe:iti:xds-sd:text:2008 = 'ITI XDS-SD TEXT', stated as 'null')</td> </tr> </table> </blockquote> </div> </text> <contained> 
    <Practitioner> 
      <id value="in-author"/> 
      <telecom> 
        <system value="email"/> 
        <value value="JohnMoehrke@gmail.com"/> 
      </telecom> 
    </Practitioner> 
  </contained> 
  <contained> 
    <Patient> 
      <id value="in-patient"/> 
    </Patient> 
  </contained> 
  <extension url="http://hl7.org/fhir/StructureDefinition/documentreference-sourcepatient">
    <valueReference> 
      <reference value="#in-patient"/> 
    </valueReference> 
  </extension> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340"/> 
  </identifier> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:uuid:0c287d32-01e3-4d87-9953-9fcc9404eb21"/> 
  </identifier> 
  <status value="current"/> 
  <type> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="55107-7"/> 
    </coding> 
  </type> 
  <category> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="11369-6"/> 
    </coding> 
  </category> 
  <subject> 
    <reference value="Patient/xcda"/> 
  </subject> 
<!--    should not be able to include this as there is a facilityType and/or practiceSetting
    <context>
    <reference value="Encounter/example"/>
  </context>
     -->
  <event> 
    <concept> 
      <coding> 
        <system value="http://terminology.hl7.org/CodeSystem/v3-ActCode"/> 
        <code value="ACCTRECEIVABLE"/> 
      </coding> 
    </concept> 
  </event> 
  <event> 
    <reference> 
      <identifier> 
        <system value="urn:ietf:rfc:3986"/> 
        <value value="urn:oid:1.2.840.113556.1.8000.2554.17917.46600.21181.17878.33419.62048.57128.2759"/> 
      </identifier> 
    </reference> 
  </event> 

  <facilityType> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="82242000"/> 
    </coding> 
  </facilityType> 
  <practiceSetting> 
    <coding> 
      <system value="http://snomed.info/sct"/> 
      <code value="408467006"/> 
    </coding> 
  </practiceSetting> 
  <period> 
    <start value="2020-12-31T23:50:50-05:00"/> 
    <end value="2020-12-31T23:50:50-05:00"/> 
  </period> 
  <date value="2020-12-31T23:50:50-05:00"/> 
  <author> 
    <reference value="#in-author"/> 
  </author> 
  <attester> 
    <mode> 
      <coding> 
        <system value="http://hl7.org/fhir/composition-attestation-mode"/> 
        <code value="professional"/> 
      </coding> 
    </mode> 
    <party> 
      <reference value="#in-author"/> 
    </party> 
  </attester> 
  <relatesTo> 
    <code> 
      <coding> 
        <system value="http://hl7.org/fhir/document-relationship-type"/> 
        <code value="appends"/> 
      </coding> 
    </code> 
    <target> 
      <reference value="DocumentReference/example"/> 
    </target> 
  </relatesTo> 
  <description value="Example of a Comprehensive DocumentReference resource. This is fully filled for
   all mandatory elements and all optional elements."/> 
  <securityLabel> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/> 
      <code value="N"/> 
    </coding> 
  </securityLabel> 
  <content> 
    <attachment> 
      <contentType value="text/plain"/> 
      <language value="en"/> 
      <url value="http://example.com/nowhere.txt"/> 
      <size value="190"/> 
      <hash value="OGEzOGYyNjMzMDA2ZmQ1MzUxNDljNDRhM2E3M2YzMTI0MzdiMzQ3OA=="/> 
      <title value="DocumentReference for Comprehensive fully filled metadata"/> 
      <creation value="2020-12-31T23:50:50-05:00"/> 
    </attachment> 
    <profile> 
      <valueCoding> 
        <system value="http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode"/> 
        <code value="urn:ihe:iti:xds-sd:text:2008"/>       
      </valueCoding> 
    </profile> 
  </content> 

</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.