This page is part of the Da Vinci Payer Data Exchange (v0.1.0: STU 1 Ballot 1) based on FHIR (HL7® FHIR® Standard) R4. The current version which supersedes this version is 2.1.0. For a full list of available versions, see the Directory of published versions

3-6-13 US Core DocumentReference

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

Unstructured data
Imaging data
C-CDA documents

The essential fields to be provided in the US Core DocumentReference resource are:

R4 Hierarchical Name	R4 Name	Card.	Type
DocumentReference	DocumentReference	0..*
DocumentReference.id	id	0..1	id
DocumentReference.identifier	identifier	0..1	Identifier
DocumentReference.status	status	1..1	code
DocumentReference.type	type	1..1	CodeableConcept
DocumentReference.subject	subject	1..1	Reference(US Core Patient Profile)
DocumentReference.date	date	0..1	instant
DocumentReference.content	content	1..1	BackboneElement
DocumentReference.content.attachment	attachment	1..1	Attachment
DocumentReference.content.attachment.contentType	contentType	1..1	code
DocumentReference.content.attachment.url	url	1..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)

3-6-13-1 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"
    }
  }
}