FHIR Release 3 (STU)

This page is part of the FHIR Specification (v3.0.2: STU 3). 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 GroupMaturity Level: 3 Trial UseCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the DocumentReference resource.

DocumentReference
Definition

A reference to a document.

Control1..1
Comments

Usually, this is used for documents other than those defined by FHIR.

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.

Control0..1
TypeIdentifier
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.).

Summarytrue
Comments

CDA Document Id extension and root.

DocumentReference.identifier
Definition

Other identifiers associated with the document, including version independent identifiers.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..*
TypeIdentifier
Summarytrue
DocumentReference.status
Definition

The status of this document reference.

Control1..1
Terminology BindingDocumentReferenceStatus (Required)
Typecode
Is Modifiertrue
Summarytrue
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
Definition

The status of the underlying document.

Control0..1
Terminology BindingCompositionStatus (Required)
Typecode
Summarytrue
Comments

The document that is pointed to might be in various lifecycle states.

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.

Control1..1
Terminology BindingDocument Type Value Set (Preferred)
TypeCodeableConcept
Summarytrue
Comments

Key metadata element describing the document, used in searching/filtering.

DocumentReference.class
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.

Control0..1
Terminology BindingDocument Class Value Set (Example)
TypeCodeableConcept
Requirements

Helps humans to assess whether the document is of interest when viewing a list of documents.

Alternate Nameskind
Summarytrue
Comments

This is a metadata field from XDS/MHD .

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).

Control0..1
TypeReference(Patient | Practitioner | Group | Device)
Summarytrue
DocumentReference.created
Definition

When the document was created.

Control0..1
TypedateTime
Summarytrue
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.

Control1..1
Typeinstant
Summarytrue
Comments

Referencing/indexing time is used for tracking, organizing versions and searching.

DocumentReference.author
Definition

Identifies who is responsible for adding the information to the document.

Control0..*
TypeReference(Practitioner | Organization | Device | Patient | RelatedPerson)
Summarytrue
Comments

Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).

DocumentReference.authenticator
Definition

Which person or organization authenticates that this document is valid.

Control0..1
TypeReference(Practitioner | Organization)
Summarytrue
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
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Control0..1
TypeReference(Organization)
Summarytrue
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.relatesTo
Definition

Relationships that this document has with other document references that already exist.

Control0..*
Is Modifiertrue
Summarytrue
Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

DocumentReference.relatesTo.code
Definition

The type of relationship that this document has with anther document.

Control1..1
Terminology BindingDocumentRelationshipType (Required)
Typecode
Summarytrue
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.

Control1..1
TypeReference(DocumentReference)
Summarytrue
DocumentReference.description
Definition

Human-readable description of the source document. This is sometimes known as the "title".

Control0..1
Typestring
Requirements

Helps humans to assess whether the document is of interest.

Summarytrue
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.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.

Control0..*
Terminology BindingAll Security Labels (Extensible)
TypeCodeableConcept
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Summarytrue
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
Definition

The document and format referenced. There may be multiple content element repetitions, each with a different format.

Control1..*
Summarytrue
DocumentReference.content.attachment
Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Control1..1
TypeAttachment
Summarytrue
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.

Control0..1
Terminology BindingDocumentReference Format Code Set (Preferred)
TypeCoding
Summarytrue
Comments

Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

DocumentReference.context
Definition

The clinical context in which the document was prepared.

Control0..1
Summarytrue
Comments

These values are primarily added to help with searching for interesting/relevant documents.

DocumentReference.context.encounter
Definition

Describes the clinical encounter or type of care that the document content is associated with.

Control0..1
TypeReference(Encounter)
Summarytrue
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.

Control0..*
Terminology Bindingv3 Code System ActCode (Example)
TypeCodeableConcept
Summarytrue
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.

Control0..1
TypePeriod
Summarytrue
DocumentReference.context.facilityType
Definition

The kind of facility where the patient was seen.

Control0..1
Terminology BindingFacility Type Code Value Set (Example)
TypeCodeableConcept
Summarytrue
DocumentReference.context.practiceSetting
Definition

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Control0..1
Terminology BindingPractice Setting Code Value Set (Example)
TypeCodeableConcept
Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Summarytrue
Comments

The value set for this content has an example binding because it is a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR and XDM for Direct Messaging Specification, Version 1), as well as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * XDS Connect-a-thon practiceSettingCode.

DocumentReference.context.sourcePatientInfo
Definition

The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Control0..1
TypeReference(Patient)
Summarytrue
DocumentReference.context.related
Definition

Related identifiers or resources associated with the DocumentReference.

Control0..*
Summarytrue
Comments

May be identifiers or resources that caused the DocumentReference or referenced Document to be created.

DocumentReference.context.related.identifier
Definition

Related identifier to this DocumentReference. If both id and ref are present they shall refer to the same thing.

NoteThis is a business identifer, not a resource identifier (see discussion)
Control0..1
TypeIdentifier
Summarytrue
Comments

Order numbers, accession numbers, XDW workflow numbers.

DocumentReference.context.related.ref
Definition

Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thing.

Control0..1
TypeReference(Any)
Summarytrue
Comments

Order, ProcedureRequest, Procedure, EligibilityRequest, etc.