This page is part of the FHIR Specification (v0.01: Historical Archive Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions

Document

A documentation of clinical observations and services that are aggregated together into a single statement of clinical meaning that establishes it's own context. A clinical document is composed of a set of resources that include both human and computer readable portions. A human must attest to the accuracy of the human readable portion, and may authenticate and/or sign the entire whole.

The relative url is /documents

Content

UML Image

<Document xmlns="http://www.hl7.org/fhir">
  <id> mand id Master Resource Id = document Id</id>
  <instant> mand instant Document Creation Time</instant>
  <type> mand CodeableConcept Document Type (LOINC if possible)</type>
  <title> opt string Document Title</title>
  <setId> cond id Id fixed across all document revisions</setId>
  <version> opt integer used to version successive replacement documents</version>
  <replaces> cond id If this document replaces another</replaces>
  <subject> mand (Patient|Group) who the document is about</subject>
  <author> mand  <!-- One+ Author (contributed content to document) -->
   <time> opt dateTime When authoring happened</time>
   <party> mand (Person|Device) who/what authored the final document</party>
  </author>
  <attestor> opt  <!-- Zero+ attests to accuracy of document -->
   <mode> mand code personal | professional | legal | official</mode>
   <time> opt dateTime When document attested</time>
   <party> opt (Person|Organisation) who attested the document</party>
  </attestor>
  <recipient> opt Zero+ (Person|Organization) expected to receive a copy </recipient>
  <custodian> mand (Organization) org which maintains the document.</custodian>
  <event> opt (Any) the clinical item being documented</event>
  <encounter> opt (Admission|InterestOfCare) context of the document</encounter>
  <section> mand  <!-- One+ Document is broken into sections -->
   <type> opt CodeableConcept type of section (recommended)</type>
   <instant> opt instant Section Creation Time</instant>
   <author> opt  <!-- if section author different to document -->
    <time> opt dateTime When authoring happened</time>
    <party> mand (Person|Device) who/what authored the section</party>
   </author>
   <enterer> opt (Person|Device) The source of the data entry</enterer>
   <subject> opt (Person|Group) if section different to document</subject>
   <informant> opt (Person) provided information in section</informant>
   <content> cond (Any) the actual content of the section</content>
   <section> cond  <!-- Zero+ nested Section -->
     <!-- Content as for Document.Section -->
   </section>
  </section>
  <extensions> opt See Extensions   See Extensions </extensions>
  <text> mand Narrative Text summary of message, for human interpretation</text>
</Document>

Schema for Document and an example (or formatted for browser)

Terminology Bindings

Document.type is bound to the concept domain DocumentType: "Type of a clinical document". If an appropriate code exists in LOINC then it should be used

Document.attestor.mode is bound to the concept domain DocumentAuthenticationMode: "The way in which a person authenticated a document". Possible values:

personal	The person authenticated the document in their personal capacity
professional	The person authenticated the document in their professional capacity
legal	The person authenticated the document and accepted legal responsibility for it's content
official	The organization authenticated the document as consistent with their policies and procedures

Document.section.type is bound to the concept domain DocumentSectionType: "Type of a clinical document section". If an appropriate code exists in LOINC then it should be used

Notes:

The Document resource can be used in a RESTful framework as a stand-alone resource, or as the basis for a full document in the document framework.
The author and the attestor are often the same person, but this may not be the case in many clinical workflows
The attestor attests to the collated narrative portions of the resources
The author, subject, enterer, and informant features are inherited in contained sections, and need not be repeated. Specifying any of these in a section replaces the inherited value
The custodian is responsible for the maintainance of the document. Principally, they are responsible for the policy regarding persistence of the documents. They need not actually retain a copy of the document, but they should do so.

Displaying a document

The human display of the Document is the collated narrative portions of following resources (in order):

The Document itself
The subject resource
Resources referenced in the section.content

The document narrative should summarise the important parts of the document header that are required to establish clinical context for the document (other than the subject, which is displayed in it's own right). To actually build the combined narrative, simply append all the narratives xhtml fragments. The viewer program can provide it's own stylesheet (.css) for the combined html of the narrative, but cannot change any styles specified internally in the existing narratives.

Originator Responsibilities

A document originator is an application that creates a document resource. The originator may create new content resources or assemble already existing content resources while doing so. A document originator has the following responsibilities:

Build a document that conforms to the Document rules, and links to content resources that also conform to the rules for the resources
Ensure that the content of the document is frozen and easily reproducible, either by aggregating the document, or using version specific resource references in a FHIR conformant RESTful framework
Ensure that the content of the documend and other resources conforms to any applicable conformance statements and declared clinical patterns.

Recipient Responsibilities

A document recipient is an application that receives documents from a document originator or document management system. The document recipient is responsible for ensuring that received CDA documents are processed and/or rendered in accordance to this specification. A document recipient has the following responsibilities:

Assume default values where they are defined in the FHIR specification (see the list here)
Render the document following the rules described above
A recipient is allowed to extract resources or data from the document, but doing so voids the attestation, and the recipient should always ensure that the user can access the original document when displaying extracted data
Warn users when a superceded document is displayed, and either withdraw data extracted from superceded documents, or warn users when they view it

Formal Definitions

The formal definitions for the elements above. Also available as an XML file.

Document
Definition	A documentation of clinical observations and services that are aggregated together into a single statement of clinical meaning that establishes it's own context. A clinical document is composed of a set of resources that include both human and computer readable portions. A human must attest to the accuracy of the human readable portion, and may authenticate and/or sign the entire whole
Control	Mandatory, 1..1
Must Understand	true
Requirements	For document based framework
To Do	Confidentiality? Language? Consent? Signatures
Document.id
Definition	the unique id of a clinical document
Control	Mandatory, 1..1
Type	id
Must Understand	true
Requirements	Each document needs a unique identifier so other documents and underlying infrastructure can reference it
Comments	must be globally unique. UUIDs are recommended
Document.instant
Definition	the document creation time, when the document first came into being. Where the CDA document is a transform from an original document in some other format, the ClinicalDocument.effectiveTime is the time the original document is created.
Control	Mandatory, 1..1
Type	instant
Must Understand	true
Document.type
Definition	specifying the particular kind of document (e.g. History and Physical, Discharge Summary, Progress Note)
Control	Mandatory, 1..1
Type	CodeableConcept from DocumentType
Must Understand	true
Document.title
Definition	the title of the document
Control	Optional, 0..1
Type	string
Comments	It's commonly the case that clinical documents do not have a title, and are collectively referred to by the display name of Document.type (e.g. a "consultation" or "progress note"). Where these display names are rendered to the clinician, or where the document has a unique title, the Document.title value should be used
Document.setId
Definition	Represents an identifier that is common across all document revisions
Control	Conditional, 0..1: cannot have both setId and replaces
Type	id
Must Understand	true
Document.version
Definition	used to version successive replacement documents
Control	Optional, 0..1
Type	integer
Must Understand	true
Comments	An integer value is recommended
Document.replaces
Definition	If this document replaces another
Control	Conditional, 0..1: cannot have both setId and replaces
Type	id
Must Understand	true
Document.subject
Definition	who the document is about
Control	Mandatory, 1..1
Type	Resource(Patient\|Group)
Must Understand	true
Document.author
Definition	Author (contributed content to document)
Control	Mandatory, 1..*
Document.author.time
Definition	When authoring happened
Control	Optional, 0..1
Type	dateTime
Document.author.party
Definition	who/what authored the final document
Control	Mandatory, 1..1
Type	Resource(Person\|Device)
Document.attestor
Definition	a participant who has attested to the accuracy of the document
Control	Optional, 0..*
Document.attestor.mode
Definition	The type of attestation the authenticator offers
Control	Mandatory, 1..1
Type	code from DocumentAuthenticationMode
Document.attestor.time
Definition	When document attested
Control	Optional, 0..1
Type	dateTime
Document.attestor.party
Definition	who attested the document
Control	Optional, 0..1
Type	Resource(Person\|Organisation)
Document.recipient
Definition	expected to receive a copy
Control	Optional, 0..*
Type	Resource(Person\|Organization)
Document.custodian
Definition	org which maintains the document.
Control	Mandatory, 1..1
Type	Resource(Organization)
Document.event
Definition	the main Act, such as a colonoscopy or an appendectomy, being documented
Control	Optional, 0..1
Type	Resource(Any)
Comments	The event needs to be consistent with the type element, though can provide further information if desired
Document.encounter
Definition	context of the document
Control	Optional, 0..1
Type	Resource(Admission\|InterestOfCare)
Document.section
Definition	Document is broken into sections
Control	Mandatory, 1..*
Document.section.type
Definition	type of section (recommended)
Control	Optional, 0..1
Type	CodeableConcept from DocumentSectionType
Document.section.instant
Definition	the section creation time (sections are often re-used in several documents).
Control	Optional, 0..1
Type	instant
Document.section.author
Definition	if section author different to document
Control	Optional, 0..1
Document.section.author.time
Definition	When authoring happened
Control	Optional, 0..1
Type	dateTime
Document.section.author.party
Definition	who/what authored the section
Control	Mandatory, 1..1
Type	Resource(Person\|Device)
Document.section.enterer
Definition	The person or device that performed the data entry leading to this section. Where there is more than one candidate, pick the most proximal to the message. Can provide other enterers in extensions
Control	Optional, 0..1
Type	Resource(Person\|Device)
Document.section.subject
Definition	if section different to document
Control	Optional, 0..1
Type	Resource(Person\|Group)
Must Understand	true
Document.section.informant
Definition	provided information in section
Control	Optional, 0..1
Type	Resource(Person)
Document.section.content
Definition	the actual content of the section
Control	Conditional, 0..1: a section must have content or one or more sections
Type	Resource(Any)
Must Understand	true
Document.section.section
Definition	nested Section
Control	Conditional, 0..*: a section must have content or one or more sections
Document.section.section.#
Definition	contents as for a section
Control	Mandatory, 1..1
Type	@Document.Section
Document.extensions
Definition	See Extensions
Control	Optional, 0..1
Document.text
Definition
Control	Mandatory, 1..1
Type	Narrative

This is an old version of FHIR retained for archive purposes. Do not use for anything else
Implementers are welcome to experiment with the content defined here, but should note that the contents are subject to change without prior notice.
© HL7.org 2011 - 2012. FHIR v0.01 generated on Mon, May 14, 2012 09:48+1000.