Da Vinci Payer Data Exchange
1.0.0 - STU1

This page is part of the Da Vinci Payer Data Exchange (v1.0.0: STU1) 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

US Core DocumentReference

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The Health Plan SHALL use the US Core DocumentReference resource to exchange:

  • Unstructured data
  • Imaging data
  • C-CDA documents

The essential fields (Must Support or Cardinality greater than 0..*) to be provided in the US Core DocumentReference resource are:

R4 Element Name Cardinality Type
DocumentReference.identifier identifier 0..* Identifier
DocumentReference.status status 1..1 code
DocumentReference.type type 1..1 CodeableConcept
DocumentReference.category category 1..* CodeableConcept
DocumentReference.subject subject 1..1 Reference(US Core Patient Profile)
DocumentReference.date date 0..1 instant
DocumentReference.author author 0..* Reference(US Core Practitioner Profile | US Core Organization Profile | US Core Patient Profile)
DocumentReference.custodian custodian 0..1 Reference(US Core Organization Profile)
DocumentReference.content content 1..* BackboneElement
DocumentReference.content.attachment attachment 1..1 Attachment
DocumentReference.content.attachment.contentType contentType 1..1 code
DocumentReference.content.attachment.data data 0..1 base64Binary
DocumentReference.content.attachment.url url 0..1 url
DocumentReference.content.format format 0..1 Coding
DocumentReference.context context 0..1 BackboneElement
DocumentReference.context.encounter encounter 0..1 Reference(US Core Encounter Profile)
DocumentReference.context.period period 0..1 Period

Table Definition

Example DocumentReference resource

An example mapping of a DocumentReference for an episode of care is shown below:

{
  "resourceType" : "DocumentReference",
  "id" : "episode-summary",
  "meta" : {
    "profile" : [
      "http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"
    ]
  },
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">
Generated Narrative with Details
id: episode-summary
meta: 
identifier: urn:oid:2.16.840.1.113883.19.5.99999.1
status: current
type: CCD Document <span style=\"background: LightGoldenRodYellow\">(Details : {LOINC code '34133-9' = 'Summary of episode note', given as 'Summary of episode note'})</span>
category: Clinical Note <span style=\"background: LightGoldenRodYellow\">(Details : {http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category code 'clinical-note' = 'Clinical Note', given as 'Clinical Note'})</span>
subject: <a href=\"Patient-example.html\">Amy Shaw. Generated Summary: id: example; Medical Record Number = 1032702 (USUAL); active; Amy V. Shaw ; ph: 555-555-5555(HOME), amy.shaw@example.com; gender: female; birthDate: Feb 20, 2007</a>
date: Mar 9, 2016, 3:29:46 PM
author: <a href=\"Practitioner-practitioner-1.html\">Ronald Bone, MD. Generated Summary: id: practitioner-1; 9941339108, 25456; Ronald Bone </a>
description: Pulmonology clinic acute visit
Contents
<table class=\"grid\">-AttachmentFormat*Documents following C-CDA constraints using a structured body (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:hl7-org:sdwg:ccda-structuredBody:2.1 = 'urn:hl7-org:sdwg:ccda-structuredBody:2.1', stated as 'Documents following C-CDA constraints using a structured body')</table>
Contexts
<table class=\"grid\">-Period*Dec 22, 2004, 9:00:00 PM --> Dec 22, 2004, 9:01:00 PM</table></div>"
  },
  "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: [base]/Binary/1-note"
      },
      "format" : {
        "system" : "urn:oid:1.3.6.1.4.1.19376.1.2.3",
        "code" : "urn:hl7-org:sdwg:ccda-structuredBody:2.1",
        "display" : "Documents following C-CDA constraints using a structured body"
      }
    }
  ],
  "context" : {
    "period" : {
      "start" : "2004-12-23T08:00:00+11:00",
      "end" : "2004-12-23T08:01:00+11:00"
    }
  }
}

The following example of a DocumentReference and associated PDex Provenance resource demonstrates how an unstructured document, such as a Portable Document Format (PDF) document could be attached or embedded as base64 encoded content in a DocumentReference. The associated PDex Provenance resource identifies the source document as a PDF file.

Example: Unstructured Document with Provenance

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