US Core Implementation Guide
6.1.0 - STU6 United States of America flag

This page is part of the US Core (v6.1.0: STU6 Update) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions

Resource Profile: US Core DocumentReference Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference Version: 6.1.0
Active as of 2022-04-20 Computable Name: USCoreDocumentReferenceProfile

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

To promote interoperability and adoption through common implementation, this profile sets minimum expectations for searching and fetching patient documents including Clinical Notes using the DocumentReference resource. It identifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains the way the elements are used when using the profile. It provides the floor for standards development for specific use cases. Prior to reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of US Core DocumentReference Profile and US Core DiagnosticReport Profile for Report and Note exchange.

Example Usage Scenarios:

The following are example usage scenarios for the US Core DocumentReference profile. See the Clinical Notes section for additional detail on using this profile for Clinical Notes:

  • Query for all documents belonging to a Patient
  • Query for a specific Clinical Note type (e.g. Discharge Summary or Continuity of Care Document (CCD))
  • Query for all Clinical Notes belonging to a Patient
  • Write a new Note to a Patient’s Chart

Mandatory and Must Support Data Elements

The following data-elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each DocumentReference Must Have:

  1. a status
  2. a code describing the type of document
  3. a document category
  4. a patient
  5. document referenced (content)
  6. the MIME type (i.e. contentType) of the document

Each DocumentReference Must Support:

  1. a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
  2. date and time the reference was created
  3. an author
  4. a code identifying the specific details about the format of the document — over and above the content’s MIME type
  5. the patient encounter that is being referenced
  6. clinically relevant date

Additional USCDI Requirements

For ONC’s USCDI requirements, each DocumentReference Must Support the following additional element. This element is included in the formal definition of the profile and the DocumentReference examples.

  1. a document category limited to The US Core DocumentReferences Type Value Set, which currently is composed of a single value, “clinical note”

Profile Specific Implementation Guidance:

  • See Clinical Notes
  • The DocumentReference.type binding Must Support, at a minimum, the 5 Common Clinical Notes and may extend to the whole US Core DocumentReference Type Value Set
  • In addition to the US Core DocumentReference Category value set, other category schemes such as the LOINC-based Document Class Value Set and IHE XDSclassCode may be used to facilitate the sharing of health documents.
  • For a C-CDA Clinical Summary of Care (CCD):
    • The document type code is the LOINC code 34133-9 Summary of episode note.
    • The format code is urn:hl7-org:sdwg:ccda-structuredBody:2.1
  • The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.attachment.url or the content as inline base64 encoded data using DocumentReference.attachment.data.
    • Although both are marked as Must Support, the server system is not required to support an address and inline base64 encoded data, but SHALL support at least one of these elements.
    • The client application SHALL support both elements.
    • The content.url may refer to a FHIR Binary Resource (i.e. [base]/Binary/[id]), FHIR Document Bundle (i.e. [base]/Bundle/[id], or another endpoint.
      • If the endpoint is outside the FHIR base URL, it SHOULD NOT require additional authorization to access.
  • Every DocumentReference must have a responsible Organization. The organization responsible for the DocumentReference SHALL be present either in DocumentReference.custodian or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who or Provenance.agent.onBehalfOf.
    • Some systems may also expose the same organization in referenced Encounter in Encounter.serviceProvider.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... identifier S0..*Identifier(USCDI) Other identifiers for the document
... status S1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type S1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category S1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
.... category:uscore 0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

... subject S1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date S0..1instant(USCDI) When this document reference was created
... author S0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)(USCDI) Who and/or what authored the document
... content S1..*BackboneElement(USCDI) Document referenced
.... attachment SC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S0..1code(USCDI) Mime type of the content, with charset etc.
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SC0..1url(USCDI) Uri where the data can be found
.... format S0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context S0..1BackboneElement(USCDI) Clinical context of document
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... period S0..1Period(USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*Identifier(USCDI) Other identifiers for the document
... status ?!SΣ1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category SΣ1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date SΣ0..1instant(USCDI) When this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile)(USCDI) Who and/or what authored the document
... content SΣ1..*BackboneElement(USCDI) Document referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ0..1code(USCDI) Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SΣC0..1url(USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElement(USCDI) Clinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... period SΣ0..1Period(USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*Identifier(USCDI) Other identifiers for the document
... status ?!SΣ1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category SΣ1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date SΣ0..1instant(USCDI) When this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)(USCDI) Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElement(USCDI) Document referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ0..1code(USCDI) Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SΣC0..1url(USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElement(USCDI) Clinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1Period(USCDI) Time of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... identifier S0..*Identifier(USCDI) Other identifiers for the document
... status S1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type S1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category S1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
.... category:uscore 0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

... subject S1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date S0..1instant(USCDI) When this document reference was created
... author S0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)(USCDI) Who and/or what authored the document
... content S1..*BackboneElement(USCDI) Document referenced
.... attachment SC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S0..1code(USCDI) Mime type of the content, with charset etc.
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SC0..1url(USCDI) Uri where the data can be found
.... format S0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context S0..1BackboneElement(USCDI) Clinical context of document
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... period S0..1Period(USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier SΣ0..*Identifier(USCDI) Other identifiers for the document
... status ?!SΣ1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category SΣ1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date SΣ0..1instant(USCDI) When this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile)(USCDI) Who and/or what authored the document
... content SΣ1..*BackboneElement(USCDI) Document referenced
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ0..1code(USCDI) Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SΣC0..1url(USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElement(USCDI) Clinical context of document
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... period SΣ0..1Period(USCDI) Time of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

IdGradePath(s)DetailsRequirements
dom-2errorDocumentReferenceIf the resource is contained in another resource, it SHALL NOT contain nested Resources
: contained.contained.empty()
dom-3errorDocumentReferenceIf the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
: contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
: contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5errorDocumentReferenceIf a resource is contained in another resource, it SHALL NOT have a security label
: contained.meta.security.empty()
dom-6best practiceDocumentReferenceA resource should have narrative for robust management
: text.`div`.exists()
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..*DocumentReferenceA reference to a document
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... masterIdentifier Σ0..1IdentifierMaster Version Specific Identifier
... identifier SΣ0..*Identifier(USCDI) Other identifiers for the document
... status ?!SΣ1..1code(USCDI) current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ0..1codepreliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ1..1CodeableConcept(USCDI) Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is DOC in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note TypeMin Binding
... Slices for category SΣ1..*CodeableConcept(USCDI) Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ0..*CodeableConcept(USCDI) Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ1..1Reference(US Core Patient Profile)(USCDI) Who/what is the subject of the document
... date SΣ0..1instant(USCDI) When this document reference was created
... author SΣ0..*Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device)(USCDI) Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ0..*BackboneElementRelationships to other documents
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1codereplaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ1..1Reference(DocumentReference)Target of the relationship
... description Σ0..1stringHuman-readable description
... securityLabel Σ0..*CodeableConceptDocument security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ1..*BackboneElement(USCDI) Document referenced
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... attachment SΣC1..1Attachment(USCDI) Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ0..1code(USCDI) Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ0..1codeHuman language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding

Example General: en-AU
..... data SC0..1base64Binary(USCDI) Data inline, base64ed
..... url SΣC0..1url(USCDI) Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ0..1unsignedIntNumber of bytes of content (if url provided)
..... hash Σ0..1base64BinaryHash of the data (sha-1, base64ed)
..... title Σ0..1stringLabel to display in place of the data
Example General: Official Corporate Logo
..... creation Σ0..1dateTimeDate attachment was first created
.... format SΣ0..1Coding(USCDI) Format/content rules for the document
Binding: DocumentReferenceFormatCodeSet (extensible)
... context SΣ0..1BackboneElement(USCDI) Clinical context of document
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... encounter S0..1Reference(US Core Encounter Profile)(USCDI) Context of the document content
.... event 0..*CodeableConceptMain clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ0..1Period(USCDI) Time of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Resource)Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.statusrequiredDocumentReferenceStatus
DocumentReference.docStatusrequiredCompositionStatus
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
DocumentReference.categoryexampleDocumentClassValueSet
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
DocumentReference.securityLabelextensibleAll Security Labels
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
DocumentReference.content.formatextensibleDocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.eventexampleActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet

Constraints

IdGradePath(s)DetailsRequirements
ele-1error**ALL** elementsAll FHIR elements must have a @value or children
: hasValue() or (children().count() > id.count())
ext-1error**ALL** extensionsMust have either extensions or value[x], not both
: extension.exists() != value.exists()
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:


Quick Start


Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

  • The syntax used to describe the interactions is described here.

  • Servers providing access to clniical note data can use US Core SMART Scopes for:
    • resource level scopes (for example, patient/DocumentReference.rs)
    • granular scopes (for example, patient.DocumentReference.rs?category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note).
  • See the General Requirements section for additional rules and expectations when a server requires status parameters.
  • See the General Guidance section for additional guidance on searching for multiple patients.

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support both read DocumentReference by id AND DocumentReference search using the _id search parameter:

    GET [base]/DocumentReference/[id] or GET [base]/DocumentReference?_id=[id]

    Example:

    1. GET [base]/DocumentReference/2169591
    2. GET [base]/DocumentReference?_id=2169591

    Implementation Notes: Fetches a single DocumentReference. The document itself is represented as a base64 encoded binary data element or retrieved using the link provided by the resource. If the document is a relative link to a [Binary] resource like a resource reference, it can be subsequently retrieved using: GET [base]/Binary/[id]. (how to search by the logical id of the resource)

  2. SHALL support searching for all documentreferences for a patient using the patient search parameter:

    GET [base]/DocumentReference?patient={Type/}[id]

    Example:

    1. GET [base]/DocumentReference?patient=1137192

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient. See the implementation notes above for how to access the actual document. (how to search by reference)

  3. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

    Example:

    1. GET [base]/DocumentReference?patient=1235541&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical-note. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

  4. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/DocumentReference?patient=1235541&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical=note and date. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)

  5. SHALL support searching using the combination of the patient and type search parameters:

    GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]

    Example:

    1. GET [base]/DocumentReference?patient=1316024&type=http://loinc.org|18842-5

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DocumentReference?patient=1235541

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and status. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and type and period search parameters:
    • including support for these period comparators: gt,lt,ge,le
    • including optional support for AND search on period (e.g.period=[date]&period=[date]]&...)

    GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/DocumentReference?patient=2169591&type=http://loinc.org |34133-9&period=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and period. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)

Mandatory Write Capability:

  1. SHALL support writing a new note to a Patient’s Chart:

    POST [base]/DocumentReference

An example to demonstrate writing a note to the server.

Clinical Note


{
  "resourceType" : "DocumentReference",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
  },
  "status" : "current",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "18842-5",
      "display" : "Discharge Summary"
    }],
    "text" : "Discharge Summary"
  },
  "category" : [{
    "coding" : [{
      "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
      "code" : "clinical-note",
      "display" : "Clinical Note"
    }],
    "text" : "Clinical No"
  }],
  "subject" : {
    "reference" : "Patient/example"
  },
  "content" : [{
    "attachment" : {
      "contentType" : "text/plain",
      "data" : "Tm8gYWN0aXZpdHkgcmVzdHJpY3Rpb24sIHJlZ3VsYXIgZGlldCwgZm9sbG93IHVwIGluIHR3byB0byB0aHJlZSB3ZWVrcyB3aXRoIHByaW1hcnkgY2FyZSBwcm92aWRlci4="
    }
  }],
  "context" : {
    "encounter" : [{
      "reference" : "Encounter/example-1"
    }]
  }
}

Note Content

The content is Base64 encoded and states: “No activity restriction, regular diet, follow up in two to three weeks with primary care provider.”


Mandatory Operation:

  1. SHALL support fetching documents using the $docref operation.

    This $docref operation is used to request a server generate a document based on the specified parameters. This operation is invoked on a FHIR Server’s DocumentReference endpoint (e.g., [base]/DocumentReference/$docref) and operates across all DocumentReference instances returning a Bundle of DocumentReference resources. See the $docref operation definition for detailed documentation.

    • The operation can be invoked using the GET Syntax if the complex type parameter is omitted:

      GET [base]/DocumentReference/$docref?{parameters}

    • Otherwise the POST transaction with used as follows:

      POST [base]/DocumentReference/$docref

      The body of the POST contains the Parameters resource with the $docref operation input parameters.

Example 1: Request the latest CCD

Request the latest CCD for a patient using GET syntax

GET [base]/DocumentReference/$docref?patient=123

Request the latest CCD for a patient using POST syntax

POST [base]/DocumentReference/$docref}

POST request body:

    {
      "resourceType": "Parameters",
      "id": "get-ccd123",
      "parameter": [
        {
          "name": "patient",
          "valueId" : "123"
        }
      ]
    }

Response

HTTP/1.1 200 OK
[other headers]

Response body


{
  "resourceType" : "Bundle",
  "id" : "docref-example-1",
  "type" : "searchset",
  "total" : 1,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/DocumentReference/$docref?patient=123"
  }],
  "entry" : [{
    "fullUrl" : "http://example.org/DocumentReference/ccd123",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "ccd123",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "identifier" : [{
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:2.16.840.1.113883.19.5.99999.1"
      }],
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "34133-9",
          "display" : "Summary of episode note"
        }],
        "text" : "CCD Document"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2016-03-09T15:29:46Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Pulmonology clinic acute visit",
      "content" : [{
        "attachment" : {
          "contentType" : "text/plain",
          "url" : "Binary/1-note",
          "title" : "Uri where the data can be found: http://example.org/Binary/1-note"
        },
        "format" : {
          "system" : "http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode",
          "code" : "urn:hl7-org:sdwg:ccda-structuredBody:2.1",
          "display" : "For documents following C-CDA 2.1 constraints using a structured body."
        }
      }],
      "context" : {
        "period" : {
          "start" : "2004-12-23T08:00:00+11:00",
          "end" : "2004-12-23T08:01:00+11:00"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  }]
}


Example 2: Request Procedure Notes and Discharge Summaries for 2019

Request Procedure Notes and Discharge Summaries for 2019 using POST syntax

POST [base]/DocumentReference/$docref}

POST request body:

{
    "resourceType": "Parameters",
    "id": "get-docs",
    "parameter": [
        {
            "name": "patient",
            "valueId": "123"
        },
        {
            "name": "start",
            "valueDateTime": "2019-01-01"
        },
        {
            "name": "end",
            "valueDateTime": "2019-12-31"
        },
        {
            "name": "type",
            "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/c80-doc-typecodes",
                "code": "18842-5",
                "display": "Discharge summary"
            }
        },
        {
            "name": "type",
            "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/c80-doc-typecodes",
                "code": "28570-0",
                "display": "Procedures Note"
            }
        },
        {
            "name": "on-demand",
            "valueBoolean": true
        }
    ]
}

Response

HTTP/1.1 200 OK
[other headers]

Response body


{
  "resourceType" : "Bundle",
  "id" : "docref-example-2",
  "type" : "searchset",
  "total" : 3,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/DocumentReference/$docref?patient=123&start=2019-01-01&end=2019-01-01&type=http://terminology.hl7.org/CodeSystem/c80-doc-typecodes|18842-5,http://terminology.hl7.org/CodeSystem/c80-doc-typecodes|28570-0&ondemand=true"
  }],
  "entry" : [{
    "fullUrl" : "http://example.org/DocumentReference/procedure-note123",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "procedure-note123",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "identifier" : [{
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:2.16.840.1.113883.19.5.99999.1"
      }],
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "28570-0",
          "display" : "Procedure Note"
        }],
        "text" : "Procedure Note"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/procedure-note123.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-02"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/DocumentReference/procedure-note456",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "procedure-note456",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "28570-0",
          "display" : "Procedure Note"
        }],
        "text" : "Procedure Note"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/procedure-note456.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-06-01",
          "end" : "2019-06-01"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/DocumentReference/discharge-summary789",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "discharge",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "18842-5",
          "display" : "Discharge Summary"
        }],
        "text" : "Discharge Summary"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/discharge-summary789.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-03"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  }]
}