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Formal definitions for the elements in the DocumentReference resource.
| DocumentReference | |
| Definition | A reference to a document. |
| Control | 1..1 |
| Comments | Usually, this is used for documents other than those defined by FHIR. |
| Invariants | Defined on this element Inv-1: A location or a service (or both) SHALL be provided (xpath: exists(f:location) or exists(f:service)) |
| 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. |
| Control | 1..1 |
| Type | Identifier |
| DocumentReference.identifier | |
| Definition | Other identifiers associated with the document, including version independent, source record and workflow related identifiers. |
| Control | 0..* |
| Type | Identifier |
| Comments | Other identifiers can also include Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDS Workflow Instance Identifiers. |
| DocumentReference.subject | |
| Definition | 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). |
| Control | 1..1 |
| Type | Resource(Patient | Practitioner | Group | Device) |
| DocumentReference.type | |
| Definition | Specifies the particular kind of document (e.g. Patient Summary, Discharge Summary, Prescription, etc.). |
| Control | 1..1 |
| Binding | DocumentType: (See http://hl7.org/fhir/vs/doc-codes) |
| Type | CodeableConcept |
| Comments | Key metadata element describing the document, used in searching/filtering. |
| DocumentReference.class | |
| Definition | A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type. |
| Control | 0..1 |
| Binding | DocumentClass: (See http://hl7.org/fhir/vs/xds-typecodes) |
| Type | CodeableConcept |
| Comments | Helps humans to assess whether the document is of interest when viewing an index of documents. |
| DocumentReference.author | |
| Definition | Identifies who is responsible for adding the information to the document. |
| Control | 1..* |
| Type | Resource(Practitioner | Device | Patient | RelatedPerson) |
| Comments | Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant). |
| DocumentReference.custodian | |
| Definition | Identifies the organization or group who is responsible for ongoing maintenance of and access to the document. |
| Control | 0..1 |
| Type | Resource(Organization) |
| Comments | Identifies the logical organization to go to find the current version, where to report issues, etc. This is different from the physical location of the document, which is the technical location of the document, which host may be delegated to the management of some other organization. |
| DocumentReference.policyManager | |
| Definition | A reference to a domain or server that manages policies under which the document is accessed and/or made available. |
| Control | 0..1 |
| Type | uri |
| To Do | Harmonization proposal to define participation type. (And evaluate whether this is in the 80%). |
| DocumentReference.authenticator | |
| Definition | Which person or organization authenticates that this document is valid. |
| Control | 0..1 |
| Type | Resource(Practitioner | Organization) |
| DocumentReference.created | |
| Definition | When the document was created. |
| Control | 0..1 |
| Type | dateTime |
| Comments | Creation time is used for tracking, organizing versions and searching. This is the creation time of the document, not the source material on which it is based. |
| DocumentReference.indexed | |
| Definition | When the document reference was created. |
| Control | 1..1 |
| Type | instant |
| Comments | Referencing/indexing time is used for tracking, organizing versions and searching. |
| DocumentReference.status | |
| Definition | The status of this document reference. |
| Control | 1..1 |
| Binding | DocumentReferenceStatus: The status of the document reference (see http://hl7.org/fhir/document-reference-status for values) |
| Type | code |
| Is Modifier | true |
| DocumentReference.docStatus | |
| Definition | The status of the underlying document. |
| Control | 0..1 |
| Binding | ReferredDocumentStatus: (See http://hl7.org/fhir/vs/composition-status) |
| Type | CodeableConcept |
| DocumentReference.relatesTo | |
| Definition | Relationships that this document has with other document references that already exist. |
| Control | 0..* |
| Is Modifier | true |
| DocumentReference.relatesTo.code | |
| Definition | The type of relationship that this document has with anther document. |
| Control | 1..1 |
| Binding | DocumentRelationshipType: The type of relationship between documents (see http://hl7.org/fhir/document-relationship-type for values) |
| Type | code |
| Comments | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
| DocumentReference.relatesTo.target | |
| Definition | The target document of this relationship. |
| Control | 1..1 |
| Type | Resource(DocumentReference) |
| DocumentReference.description | |
| Definition | Human-readable description of the source document. This is sometimes known as the "title". |
| Control | 0..1 |
| Type | string |
| Requirements | Helps humans to assess whether the document is of interest. |
| Comments | What the document is about, rather than a terse summary of the document. It is commonly the case that records do not have a title and are collectively referred to by the display name of Record code (e.g. a "consultation" or "progress note"). |
| DocumentReference.confidentiality | |
| Definition | A code specifying the level of confidentiality of the XDS Document. |
| Control | 0..* |
| Binding | DocumentConfidentiality: Codes specifying the level of confidentiality of the composition (Value Set Definition) |
| Type | CodeableConcept |
| Is Modifier | true |
| Comments | The interpretation of this field, and more generally enforcement and issues related to highly sensitive documents are beyond the scope of this resource. confidentialityCode can only be understood in the context of the policies, procedures, and value set specified by the context in which the document reference is being used. |
| DocumentReference.primaryLanguage | |
| Definition | The primary language in which the source document is written. |
| Control | 0..1 |
| Binding | Language: see IETF language tag |
| Type | code |
| DocumentReference.mimeType | |
| Definition | The mime type of the source document. |
| Control | 1..1 |
| Binding | MimeType: see BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) |
| Type | code |
| Comments | Note: application/hl7-v3+xml for CDA. application/binary for proprietary record formats. |
| DocumentReference.format | |
| Definition | An identifier that identifies that the format and content of the document conforms to additional rules beyond the base format indicated in the mimeType. |
| Control | 0..* |
| Type | uri |
| Comments | Most often used when the mime-type is text/xml. |
| DocumentReference.size | |
| Definition | The size of the source document this reference refers to in bytes. |
| Control | 0..1 |
| Type | integer |
| DocumentReference.hash | |
| Definition | A hash of the source document to ensure that changes have not occurred. |
| Control | 0..1 |
| Type | string |
| Comments | Whether the hash must be present and/or correct depends on the document handling rules defined in the context of use. |
| DocumentReference.location | |
| Definition | A url at which the document can be accessed. |
| Control | 0..1 |
| Type | uri |
| Invariants | Affect this element Inv-1: A location or a service (or both) SHALL be provided (xpath: exists(f:location) or exists(f:service)) |
| DocumentReference.service | |
| Definition | A description of a service call that can be used to retrieve the document. |
| Control | 0..1 |
| Comments | If a document can be accessed by either a service or directly by a URL (i.e. an XDS repository with an MHD access point, or a DICOM network with a WADO portal) just provide the URL. |
| Invariants | Affect this element Inv-1: A location or a service (or both) SHALL be provided (xpath: exists(f:location) or exists(f:service)) |
| DocumentReference.service.type | |
| Definition | The type of the service that can be used to access the documents. |
| Control | 1..1 |
| Binding | DocumentServiceType: (See http://hl7.org/fhir/vs/documentreference-service-types) |
| Type | CodeableConcept |
| Comments | The meaning and interpretation of the parameters depends on the service type. |
| DocumentReference.service.address | |
| Definition | Where the service end-point is located. |
| Control | 0..1 |
| Type | string |
| Comments | Usually this is a URL, but for some services, the end-point is a simple network name or address that is not a valid URL. |
| DocumentReference.service.parameter | |
| Definition | A list of named parameters that is used in the service call. |
| Control | 0..* |
| Comments | The interpretation of the parameters, and how to convert them into a proper service call, is dependent on the type of the service, and needs to be specified in an implementation guide somewhere. |
| DocumentReference.service.parameter.name | |
| Definition | The name of a parameter. |
| Control | 1..1 |
| Type | string |
| DocumentReference.service.parameter.value | |
| Definition | The value of the named parameter. |
| Control | 0..1 |
| Type | string |
| DocumentReference.context | |
| Definition | The clinical context in which the document was prepared. |
| Control | 0..1 |
| Comments | These values are primarily added to help with searching for interesting/relevant documents. |
| 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 typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. |
| Control | 0..* |
| Binding | DocumentEventType: This list of codes represents the main clinical acts being documented (Value Set Definition) |
| 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 | |
| Definition | The time period over which the service that is described by the document was provided. |
| Control | 0..1 |
| Type | Period |
| DocumentReference.context.facilityType | |
| Definition | The kind of facility where the patient was seen. |
| Control | 0..1 |
| Binding | DocumentFacilityType: (See http://hl7.org/fhir/vs/xds-facilitycodes) |
| Type | CodeableConcept |
© HL7.org 2011+. FHIR DSTU (v0.0.82.2943) generated on Tue, Sep 30, 2014 18:09+1000.
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