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.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	(USCDI) Other identifiers for the document
status	S	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	S	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	S	1..*	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	S	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	S	0..1	instant	(USCDI) When this document reference was created
author	S	0..*	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	S	1..*	BackboneElement	(USCDI) Document referenced
attachment	SC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	S	0..1	code	(USCDI) Mime type of the content, with charset etc.
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SC	0..1	url	(USCDI) Uri where the data can be found
format	S	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	S	0..1	BackboneElement	(USCDI) Clinical context of document
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	S	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	SΣ	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	SΣ	1..*	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	Σ	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	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile)	(USCDI) Who and/or what authored the document
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	0..1	code	(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	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If 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-4	error	DocumentReference	If 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-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	SΣ	1..*	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	Σ	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	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	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..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(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..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	0..1	code	(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	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional 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..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.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

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
identifier	S	0..*	Identifier	(USCDI) Other identifiers for the document
status	S	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	S	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	S	1..*	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	S	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	S	0..1	instant	(USCDI) When this document reference was created
author	S	0..*	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	S	1..*	BackboneElement	(USCDI) Document referenced
attachment	SC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	S	0..1	code	(USCDI) Mime type of the content, with charset etc.
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SC	0..1	url	(USCDI) Uri where the data can be found
format	S	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	S	0..1	BackboneElement	(USCDI) Clinical context of document
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	S	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
type	SΣ	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	SΣ	1..*	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	Σ	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	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	Reference(US Core Practitioner Profile)	(USCDI) Who and/or what authored the document
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(USCDI) Where to access the document us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
contentType	SΣ	0..1	code	(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	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	DocumentReference	If 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-4	error	DocumentReference	If 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-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	Σ	0..1	Identifier	Master Version Specific Identifier
identifier	SΣ	0..*	Identifier	(USCDI) Other identifiers for the document
status	?!SΣ	1..1	code	(USCDI) current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
docStatus	Σ	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
type	SΣ	1..1	CodeableConcept	(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 Bindings Purpose US Core Clinical Note Type Min Binding
Slices for category	SΣ	1..*	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	Σ	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	SΣ	1..1	Reference(US Core Patient Profile)	(USCDI) Who/what is the subject of the document
date	SΣ	0..1	instant	(USCDI) When this document reference was created
author	SΣ	0..*	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..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	Σ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	Σ	0..1	string	Human-readable description
securityLabel	Σ	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
content	SΣ	1..*	BackboneElement	(USCDI) Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣC	1..1	Attachment	(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..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	0..1	code	(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	Σ	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data	SC	0..1	base64Binary	(USCDI) Data inline, base64ed
url	SΣC	0..1	url	(USCDI) Uri where the data can be found Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	Σ	0..1	dateTime	Date attachment was first created
format	SΣ	0..1	Coding	(USCDI) Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (extensible)
context	SΣ	0..1	BackboneElement	(USCDI) Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..1	Reference(US Core Encounter Profile)	(USCDI) Context of the document content
event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	SΣ	0..1	Period	(USCDI) Time of service that is being documented
facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
practiceSetting		0..1	CodeableConcept	Additional 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..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
DocumentReference.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStatus
DocumentReference.docStatus	required	CompositionStatus
DocumentReference.type	required	USCoreDocumentReferenceType Additional Bindings Purpose US Core Clinical Note Type Min Binding
DocumentReference.category	example	DocumentClassValueSet
DocumentReference.category:uscore	required	USCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
DocumentReference.relatesTo.code	required	DocumentRelationshipType
DocumentReference.securityLabel	extensible	All Security Labels
DocumentReference.content.attachment.contentType	required	Mime Types (a valid code from urn:ietf:bcp:13)
DocumentReference.content.attachment.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	extensible	DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem)
DocumentReference.context.event	example	ActCode
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
us-core-6	error	DocumentReference.content.attachment	DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists()

This structure is derived from DocumentReference

Summary

Mandatory: 3 elements
Must-Support: 16 elements

Structures

This structure refers to these other structures:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
• US Core Organization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization)
• US Core PractitionerRole Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Slices

This structure defines the following Slices:

• The element DocumentReference.category is sliced based on the value of pattern:$this

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

Click Here To See Example

{
  "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"
    }]
  }
}

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

Click Here To See Example

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

HTTP/1.1 200 OK
[other headers]

{
  "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

Click Here To See Example

{
    "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
        }
    ]
}

HTTP/1.1 200 OK
[other headers]

{
  "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"
    }
  }]
}