DSTU2 Ballot Source

This page is part of the FHIR Specification (v0.5.0: DSTU 2 Ballot 2). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

6.10 Resource DocumentReference - Content

This resource maintained by the FHIR Management Group Work Group

A reference to a document.

6.10.1 Scope and Usage

A document reference resource is used to describe a document that is made available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g. what subject, author etc), can be displayed to the user, and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type, and that conforms to this definition.

Typically, Document Reference Resources are used in document indexing systems, such as IHE XDS (see the XDS specific profile), and are used to refer to:

  • CDA documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents, and even digital records of faxes where sufficient information is available
  • Other kinds of documents, such as records of prescriptions.

6.10.2 Boundaries and Relationships

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. This resource is mainly intended for general references to other documents.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource, or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet, or a DICOM exchange, or a v2 message query, though the way each of these service calls works must be specified in some external standard or other documentation.

This resource is referenced by Contract, DiagnosticOrder and DocumentManifest

6.10.3 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference DomainResourceA reference to a document
... masterIdentifier 0..1IdentifierMaster Version Specific Identifier
... identifier 0..*IdentifierOther identifiers for the document
... subject 0..1Patient | Practitioner | Group | DeviceWho|what is the subject of the document
... type 1..1CodeableConceptKind of document
DocumentC80Type (Preferred)
... class 0..1CodeableConceptCategorization of document
DocumentC80Class (Preferred)
... format 0..*uriFormat/content rules for the document
DocumentFormat (Preferred)
... author 1..*Practitioner | Organization | Device | Patient | RelatedPersonWho and/or what authored the document
... custodian 0..1OrganizationOrg which maintains the document
... authenticator 0..1Practitioner | OrganizationWho/What authenticated the document
... created 0..1dateTimeDocument creation time
... indexed 1..1instantWhen this document reference created
... status ?!1..1codecurrent | superceded | entered-in-error
DocumentReferenceStatus (Required)
... docStatus 0..1CodeableConceptpreliminary | final | appended | amended | entered-in-error
ReferredDocumentStatus (Required)
... relatesTo ?!0..*ElementRelationships to other documents
.... code 1..1codereplaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target 1..1DocumentReferenceTarget of the relationship
... description 0..1stringHuman-readable description (title)
... confidentiality 0..*CodeableConceptDocument security-tags
HCS (Extensible)
... content 1..*AttachmentWhere to access the document
... context 0..1ElementClinical context of document
.... event 0..*CodeableConceptMain Clinical Acts Documented
.... period 0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
DocumentC80FacilityType (Preferred)
.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
DocumentC80PracticeSetting (Preferred)
.... sourcePatientInfo 0..1PatientSource patient info
.... related 0..*ElementRelated things
..... identifier 0..1IdentifierRelated Identifier
..... ref 0..1AnyRelated Resource

UML Diagram

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier 0..1Other identifiers associated with the document, including version independent identifiersidentifier : Identifier 0..*Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (I.e. machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference(Patient|Practitioner|Group| Device) 0..1Specifies the particular kind of document. This usually equates to the purpose of making the document. It is recommended that the value Set be drawn from a coding scheme providing a fine level of granularity such as LOINC. (e.g. Patient Summary, Discharge Summary, Prescription, etc.)type : CodeableConcept 1..1 « Precice type of clinical documentDocumentC80Type+ »A categorization for the type of document. The class is an abstraction from the type specifying the high-level kind of document (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow) at a macro levelclass : CodeableConcept 0..1 « High-level kind of a clinical document at a macro levelDocumentC80Class+ »An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : uri 0..* « Document Format CodesDocumentFormat+ »Identifies who is responsible for adding the information to the documentauthor : Reference(Practitioner|Organization| Device|Patient|RelatedPerson) 1..*Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference(Organization) 0..1Which person or organization authenticates that this document is validauthenticator : Reference(Practitioner|Organization) 0..1When the document was createdcreated : dateTime 0..1When the document reference was createdindexed : instant 1..1The status of this document reference (this element modifies the meaning of other elements)status : code 1..1 « The status of the document referenceDocumentReferenceStatus »The status of the underlying documentdocStatus : CodeableConcept 0..1 « Status of the underlying documentReferredDocumentStatus »Human-readable description of the source document. This is sometimes known as the "title"description : string 0..1A set of Security-Tag codes specifying the level of privacy/security of the Documentconfidentiality : CodeableConcept 0..* « Healthcare Privacy and Security Classification SystemHCS+ »The document or url to the document along with critical metadata to prove content has integritycontent : Attachment 1..*RelatesToThe type of relationship that this document has with anther documentcode : code 1..1 « The type of relationship between documentsDocumentRelationshipType »The target document of this relationshiptarget : Reference(DocumentReference) 1..1ContextThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept 0..*The time period over which the service that is described by the document was providedperiod : Period 0..1The kind of facility where the patient was seenfacilityType : CodeableConcept 0..1 « XDS Facility TypeDocumentC80FacilityType+ »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept 0..1 « Additional details about where the content was created (e.g. clinical specialty)DocumentC80PracticeSetting+ »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference(Patient) 0..1RelatedRelated identifier to this DocumentReference. If both id and ref are present they shall refer to the same thingidentifier : Identifier 0..1Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thingref : Reference(Any) 0..1Relationships that this document has with other document references that already exist (this element modifies the meaning of other elements)relatesTo0..*Related identifiers or resources associated with the DocumentReferencerelated0..*The clinical context in which the document was preparedcontext0..1

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 0..1 Reference(Patient|Practitioner|Group|Device) 
     Who|what is the subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept Kind of document --></type>
 <class><!-- 0..1 CodeableConcept Categorization of document --></class>
 <format value="[uri]"/><!-- 0..* Format/content rules for the document -->
 <author><!-- 1..* Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) Who and/or what authored the document --></author>
 <custodian><!-- 0..1 Reference(Organization) Org which maintains the document --></custodian>
 <authenticator><!-- 0..1 Reference(Practitioner|Organization) 
     Who/What authenticated the document --></authenticator>
 <created value="[dateTime]"/><!-- 0..1 Document creation time -->
 <indexed value="[instant]"/><!-- 1..1 When this document reference created -->
 <status value="[code]"/><!-- 1..1 current | superceded | entered-in-error -->
 <docStatus><!-- 0..1 CodeableConcept preliminary | final | appended | amended | entered-in-error --></docStatus>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends -->
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[string]"/><!-- 0..1 Human-readable description (title) -->
 <confidentiality><!-- 0..* CodeableConcept Document security-tags --></confidentiality>
 <content><!-- 1..* Attachment Where to access the document --></content>
 <context>  <!-- 0..1 Clinical context of document -->
  <event><!-- 0..* CodeableConcept Main Clinical Acts Documented --></event>
  <period><!-- 0..1 Period Time of service that is being documented --></period>
  <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
  <practiceSetting><!-- 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
  <sourcePatientInfo><!-- 0..1 Reference(Patient) Source patient info --></sourcePatientInfo>
  <related>  <!-- 0..* Related things -->
   <identifier><!-- 0..1 Identifier Related Identifier --></identifier>
   <ref><!-- 0..1 Reference(Any) Related Resource --></ref>
  </related>
 </context>
</DocumentReference>

JSON Template

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "masterIdentifier" : { Identifier }, // Master Version Specific Identifier
  "identifier" : [{ Identifier }], // Other identifiers for the document
  "subject" : { Reference(Patient|Practitioner|Group|Device) }, // 
     Who|what is the subject of the document
  "type" : { CodeableConcept }, // R!  Kind of document
  "class" : { CodeableConcept }, // Categorization of document
  "format" : ["<uri>"], // Format/content rules for the document
  "author" : [{ Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) }], // R!  Who and/or what authored the document
  "custodian" : { Reference(Organization) }, // Org which maintains the document
  "authenticator" : { Reference(Practitioner|Organization) }, // 
     Who/What authenticated the document
  "created" : "<dateTime>", // Document creation time
  "indexed" : "<instant>", // R!  When this document reference created
  "status" : "<code>", // R!  current | superceded | entered-in-error
  "docStatus" : { CodeableConcept }, // preliminary | final | appended | amended | entered-in-error
  "relatesTo" : [{ // Relationships to other documents
    "code" : "<code>", // R!  replaces | transforms | signs | appends
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<string>", // Human-readable description (title)
  "confidentiality" : [{ CodeableConcept }], // Document security-tags
  "content" : [{ Attachment }], // R!  Where to access the document
  "context" : { // Clinical context of document
    "event" : [{ CodeableConcept }], // Main Clinical Acts Documented
    "period" : { Period }, // Time of service that is being documented
    "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
    "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
    "sourcePatientInfo" : { Reference(Patient) }, // Source patient info
    "related" : [{ // Related things
      "identifier" : { Identifier }, // Related Identifier
      "ref" : { Reference(Any) } // Related Resource
    }]
  }
}

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference DomainResourceA reference to a document
... masterIdentifier 0..1IdentifierMaster Version Specific Identifier
... identifier 0..*IdentifierOther identifiers for the document
... subject 0..1Patient | Practitioner | Group | DeviceWho|what is the subject of the document
... type 1..1CodeableConceptKind of document
DocumentC80Type (Preferred)
... class 0..1CodeableConceptCategorization of document
DocumentC80Class (Preferred)
... format 0..*uriFormat/content rules for the document
DocumentFormat (Preferred)
... author 1..*Practitioner | Organization | Device | Patient | RelatedPersonWho and/or what authored the document
... custodian 0..1OrganizationOrg which maintains the document
... authenticator 0..1Practitioner | OrganizationWho/What authenticated the document
... created 0..1dateTimeDocument creation time
... indexed 1..1instantWhen this document reference created
... status ?!1..1codecurrent | superceded | entered-in-error
DocumentReferenceStatus (Required)
... docStatus 0..1CodeableConceptpreliminary | final | appended | amended | entered-in-error
ReferredDocumentStatus (Required)
... relatesTo ?!0..*ElementRelationships to other documents
.... code 1..1codereplaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target 1..1DocumentReferenceTarget of the relationship
... description 0..1stringHuman-readable description (title)
... confidentiality 0..*CodeableConceptDocument security-tags
HCS (Extensible)
... content 1..*AttachmentWhere to access the document
... context 0..1ElementClinical context of document
.... event 0..*CodeableConceptMain Clinical Acts Documented
.... period 0..1PeriodTime of service that is being documented
.... facilityType 0..1CodeableConceptKind of facility where patient was seen
DocumentC80FacilityType (Preferred)
.... practiceSetting 0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty)
DocumentC80PracticeSetting (Preferred)
.... sourcePatientInfo 0..1PatientSource patient info
.... related 0..*ElementRelated things
..... identifier 0..1IdentifierRelated Identifier
..... ref 0..1AnyRelated Resource

UML Diagram

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier 0..1Other identifiers associated with the document, including version independent identifiersidentifier : Identifier 0..*Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (I.e. machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference(Patient|Practitioner|Group| Device) 0..1Specifies the particular kind of document. This usually equates to the purpose of making the document. It is recommended that the value Set be drawn from a coding scheme providing a fine level of granularity such as LOINC. (e.g. Patient Summary, Discharge Summary, Prescription, etc.)type : CodeableConcept 1..1 « Precice type of clinical documentDocumentC80Type+ »A categorization for the type of document. The class is an abstraction from the type specifying the high-level kind of document (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow) at a macro levelclass : CodeableConcept 0..1 « High-level kind of a clinical document at a macro levelDocumentC80Class+ »An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : uri 0..* « Document Format CodesDocumentFormat+ »Identifies who is responsible for adding the information to the documentauthor : Reference(Practitioner|Organization| Device|Patient|RelatedPerson) 1..*Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference(Organization) 0..1Which person or organization authenticates that this document is validauthenticator : Reference(Practitioner|Organization) 0..1When the document was createdcreated : dateTime 0..1When the document reference was createdindexed : instant 1..1The status of this document reference (this element modifies the meaning of other elements)status : code 1..1 « The status of the document referenceDocumentReferenceStatus »The status of the underlying documentdocStatus : CodeableConcept 0..1 « Status of the underlying documentReferredDocumentStatus »Human-readable description of the source document. This is sometimes known as the "title"description : string 0..1A set of Security-Tag codes specifying the level of privacy/security of the Documentconfidentiality : CodeableConcept 0..* « Healthcare Privacy and Security Classification SystemHCS+ »The document or url to the document along with critical metadata to prove content has integritycontent : Attachment 1..*RelatesToThe type of relationship that this document has with anther documentcode : code 1..1 « The type of relationship between documentsDocumentRelationshipType »The target document of this relationshiptarget : Reference(DocumentReference) 1..1ContextThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept 0..*The time period over which the service that is described by the document was providedperiod : Period 0..1The kind of facility where the patient was seenfacilityType : CodeableConcept 0..1 « XDS Facility TypeDocumentC80FacilityType+ »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept 0..1 « Additional details about where the content was created (e.g. clinical specialty)DocumentC80PracticeSetting+ »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference(Patient) 0..1RelatedRelated identifier to this DocumentReference. If both id and ref are present they shall refer to the same thingidentifier : Identifier 0..1Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thingref : Reference(Any) 0..1Relationships that this document has with other document references that already exist (this element modifies the meaning of other elements)relatesTo0..*Related identifiers or resources associated with the DocumentReferencerelated0..*The clinical context in which the document was preparedcontext0..1

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 0..1 Reference(Patient|Practitioner|Group|Device) 
     Who|what is the subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept Kind of document --></type>
 <class><!-- 0..1 CodeableConcept Categorization of document --></class>
 <format value="[uri]"/><!-- 0..* Format/content rules for the document -->
 <author><!-- 1..* Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) Who and/or what authored the document --></author>
 <custodian><!-- 0..1 Reference(Organization) Org which maintains the document --></custodian>
 <authenticator><!-- 0..1 Reference(Practitioner|Organization) 
     Who/What authenticated the document --></authenticator>
 <created value="[dateTime]"/><!-- 0..1 Document creation time -->
 <indexed value="[instant]"/><!-- 1..1 When this document reference created -->
 <status value="[code]"/><!-- 1..1 current | superceded | entered-in-error -->
 <docStatus><!-- 0..1 CodeableConcept preliminary | final | appended | amended | entered-in-error --></docStatus>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code value="[code]"/><!-- 1..1 replaces | transforms | signs | appends -->
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[string]"/><!-- 0..1 Human-readable description (title) -->
 <confidentiality><!-- 0..* CodeableConcept Document security-tags --></confidentiality>
 <content><!-- 1..* Attachment Where to access the document --></content>
 <context>  <!-- 0..1 Clinical context of document -->
  <event><!-- 0..* CodeableConcept Main Clinical Acts Documented --></event>
  <period><!-- 0..1 Period Time of service that is being documented --></period>
  <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
  <practiceSetting><!-- 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
  <sourcePatientInfo><!-- 0..1 Reference(Patient) Source patient info --></sourcePatientInfo>
  <related>  <!-- 0..* Related things -->
   <identifier><!-- 0..1 Identifier Related Identifier --></identifier>
   <ref><!-- 0..1 Reference(Any) Related Resource --></ref>
  </related>
 </context>
</DocumentReference>

JSON Template

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "masterIdentifier" : { Identifier }, // Master Version Specific Identifier
  "identifier" : [{ Identifier }], // Other identifiers for the document
  "subject" : { Reference(Patient|Practitioner|Group|Device) }, // 
     Who|what is the subject of the document
  "type" : { CodeableConcept }, // R!  Kind of document
  "class" : { CodeableConcept }, // Categorization of document
  "format" : ["<uri>"], // Format/content rules for the document
  "author" : [{ Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) }], // R!  Who and/or what authored the document
  "custodian" : { Reference(Organization) }, // Org which maintains the document
  "authenticator" : { Reference(Practitioner|Organization) }, // 
     Who/What authenticated the document
  "created" : "<dateTime>", // Document creation time
  "indexed" : "<instant>", // R!  When this document reference created
  "status" : "<code>", // R!  current | superceded | entered-in-error
  "docStatus" : { CodeableConcept }, // preliminary | final | appended | amended | entered-in-error
  "relatesTo" : [{ // Relationships to other documents
    "code" : "<code>", // R!  replaces | transforms | signs | appends
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<string>", // Human-readable description (title)
  "confidentiality" : [{ CodeableConcept }], // Document security-tags
  "content" : [{ Attachment }], // R!  Where to access the document
  "context" : { // Clinical context of document
    "event" : [{ CodeableConcept }], // Main Clinical Acts Documented
    "period" : { Period }, // Time of service that is being documented
    "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
    "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
    "sourcePatientInfo" : { Reference(Patient) }, // Source patient info
    "related" : [{ // Related things
      "identifier" : { Identifier }, // Related Identifier
      "ref" : { Reference(Any) } // Related Resource
    }]
  }
}

 

Alternate definitions: Schema/Schematron, Resource Profile (XML, JSON)

6.10.3.1 Terminology Bindings

PathDefinitionTypeReference
DocumentReference.type Precice type of clinical documentPreferredhttp://hl7.org/fhir/vs/c80-doc-typecodes
DocumentReference.class High-level kind of a clinical document at a macro levelPreferredhttp://hl7.org/fhir/vs/c80-doc-classcodes
DocumentReference.format Document Format CodesPreferredhttp://hl7.org/fhir/vs/formatcodes
DocumentReference.status The status of the document referenceRequiredhttp://hl7.org/fhir/document-reference-status
DocumentReference.docStatus Status of the underlying documentRequiredhttp://hl7.org/fhir/vs/composition-status
DocumentReference.relatesTo.code The type of relationship between documentsRequiredhttp://hl7.org/fhir/document-relationship-type
DocumentReference.confidentiality Healthcare Privacy and Security Classification SystemExtensiblehttp://hl7.org/fhir/vs/security-labels
DocumentReference.context.facilityType XDS Facility TypePreferredhttp://hl7.org/fhir/vs/c80-facilitycodes
DocumentReference.context.practiceSetting Additional details about where the content was created (e.g. clinical specialty)Preferredhttp://hl7.org/fhir/vs/c80-practice-codes

6.10.4 Implementation Notes

  • The use of the .docStatus codes is discussed in the Composition description
  • The resources maintain one way relationships that point backwards - e.g. the document that replaces one document points towards the document that it replaced. The reverse relationships can be followed by using indexes built from the resources. Typically, this is done using the search parameters described below. Given that documents may have other documents that replace or append them, clients should always check these relationships when accessing documents

6.10.4.1 Document Formats

In addition to a mime type (which is mandatory), there is also a format element which carries a URI. This element has one or more identifiers that indicate that the format and/or content of the document conforms to additional rules beyond the base format indicated in the mimeType. This is most often used when the mime-type is text/xml, to provide additional information for finding the correct document.

Defined URIs:

  • ASTM CCR: urn:astm-org:CCR
  • CCDA: urn:hl7-org:sdwg:ccda-level-1:1.1, urn:hl7-org:sdwg:ccda-level-2:1.1 and urn:hl7-org:sdwg:ccda-level-3:1.1
  • IHE defines URIs here and OIDs here (prefix OIDs with urn:oid: in the resource).

Other URIs can be used for items not on this list.

6.10.4.2 Generating a Document Reference

A client can ask a server to generate a document reference from a document. The server reads the existing document and generates a matching DocumentReference resource, or returns one it has previously generated. Servers may be able to return or generate document references for the following types of content:

Type Comments
FHIR Documents The uri refers to an existing Document
CDA Document The uri is a reference to a Binary end-point that returns either a CDA document, or some kind of CDA Package that the server knows how to process (e.g. an IHE .zip)
Other The server can be asked to generate a document reference for other kinds of documents. For some of these documents (e.g. PDF documents) a server could only provide a DocumentReference it is already existed, or the server had special knowledge of the document

The server either returns a search result containing a single DocumentReference, or it returns an error. If some the URI refers to another server, it is at the discretion of the server whether to retrieve it or return an error.

The operation is initiated by a named query, using _query=generate on the /DocumentReference end point: 

  GET [service-url]/DocumentReference/?_query=generate&uri=:url&...

The "uri" parameter is a relative or absolute reference to one of the document types described above. Other parameters may be supplied:

Name Meaning
persist Whether to store the document at the document end-point (/Document) or not once it is generated. Value = true or false (default is for the server to decide)

6.10.5 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

NameTypeDescriptionPaths
authenticatorreferenceWho/What authenticated the documentDocumentReference.authenticator
(Organization, Practitioner)
authorreferenceWho and/or what authored the documentDocumentReference.author
(Device, Patient, Organization, Practitioner, RelatedPerson)
classtokenCategorization of documentDocumentReference.class
confidentialitytokenDocument security-tagsDocumentReference.confidentiality
createddateDocument creation timeDocumentReference.created
custodianreferenceOrg which maintains the documentDocumentReference.custodian
(Organization)
descriptionstringHuman-readable description (title)DocumentReference.description
eventtokenMain Clinical Acts DocumentedDocumentReference.context.event
facilitytokenKind of facility where patient was seenDocumentReference.context.facilityType
formaturiFormat/content rules for the documentDocumentReference.format
identifiertokenMaster Version Specific IdentifierDocumentReference.masterIdentifier, DocumentReference.identifier
indexeddateWhen this document reference createdDocumentReference.indexed
languagetokenHuman language of the content (BCP-47)DocumentReference.content.language
locationuriUri where the data can be foundDocumentReference.content.url
patientreferenceWho|what is the subject of the documentDocumentReference.subject
(Patient)
perioddateTime of service that is being documentedDocumentReference.context.period
relatedidtokenRelated IdentifierDocumentReference.context.related.identifier
relatedrefreferenceRelated ResourceDocumentReference.context.related.ref
(Any)
relatestoreferenceTarget of the relationshipDocumentReference.relatesTo.target
(DocumentReference)
relationtokenreplaces | transforms | signs | appendsDocumentReference.relatesTo.code
relationshipcompositeCombination of relation and relatesTo
settingtokenAdditional details about where the content was created (e.g. clinical specialty)DocumentReference.context.practiceSetting
statustokencurrent | superceded | entered-in-errorDocumentReference.status
subjectreferenceWho|what is the subject of the documentDocumentReference.subject
(Device, Patient, Practitioner, Group)
typetokenKind of documentDocumentReference.type