This page is part of the FHIR Specification (v4.6.0: R5 Draft Ballot). 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
| Orders and Observations Work Group | Maturity Level: N/A | Standards Status: Informative | Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson |
Raw JSON (canonical form + also see JSON Format Specification)
Generic example
{
"resourceType": "DocumentReference",
"id": "example",
"text": {
"status": "generated",
"div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative</b></p><p><b>identifier</b>: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p><p><b>status</b>: current</p><p><b>docStatus</b>: preliminary</p><p><b>type</b>: <span>Outpatient Note</span></p><p><b>category</b>: <span>History and Physical</span></p><p><b>subject</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p><p><b>encounter</b>: <a>Generated Summary: id: 1234213.52345873 (OFFICIAL); status: completed; <span>ambulatory</span></a></p><p><b>event</b>: <span>Arm</span></p><p><b>facilityType</b>: <span>Outpatient</span></p><p><b>practiceSetting</b>: <span>General Medicine</span></p><p><b>period</b>: 23 Dec. 2004, 8:00:00 am --> 23 Dec. 2004, 8:01:00 am</p><p><b>date</b>: 24 Dec. 2005, 9:43:41 am</p><p><b>author</b>: </p><ul><li><a>Generated Summary: id: D234123 (OFFICIAL); Sherry Dopplemeyer ; john.doe@healthcare.example.org</a></li><li><a> </a></li></ul><blockquote><p><b>name</b>: Gerald Smitty </p></blockquote><h3>Attesters</h3><table><tr><td>-</td><td><b>Mode</b></td><td><b>Party</b></td></tr><tr><td>*</td><td>official</td><td><a>Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); <span>University Medical Hospital</span>; name: Burgers University Medical Center; Phone: 022-655 2300</a></td></tr></table><p><b>custodian</b>: <a>Generated Summary: id: 91654 (OFFICIAL), id: 17-0112278 (USUAL); <span>University Medical Hospital</span>; name: Burgers University Medical Center; Phone: 022-655 2300</a></p><h3>RelatesTos</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>appends</td><td><a>Generated Summary: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234; status: current; docStatus: preliminary; <span>Outpatient Note</span>; <span>History and Physical</span>; <span>Arm</span>; <span>Outpatient</span>; <span>General Medicine</span>; period: 23 Dec. 2004, 8:00:00 am --> 23 Dec. 2004, 8:01:00 am; date: 24 Dec. 2005, 9:43:41 am; description: Physical; <span>very restricted</span></a></td></tr></table><p><b>description</b>: Physical</p><p><b>securityLabel</b>: <span>very restricted</span></p><blockquote><p><b>content</b></p><h3>Attachments</h3><table><tr><td>-</td></tr><tr><td>*</td></tr></table><p><b>format</b>: <span>History and Physical Specification</span></p><p><b>identifier</b>: id: urn:oid:1.3.6.1.4.1.21367.2005.3.7</p></blockquote><p><b>sourcePatientInfo</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p><p><b>related</b>: <a>Generated Summary: Medical record number: 12345 (USUAL); active; Henry Levin ; gender: male; birthDate: 1932-09-24</a></p></div>"
},
"contained": [
{
"resourceType": "Practitioner",
"id": "a2",
"name": [
{
"family": "Smitty",
"given": [
"Gerald"
]
}
]
}
],
"identifier": [
{
"system": "urn:ietf:rfc:3986",
"value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"
}
],
"status": "current",
"docStatus": "preliminary",
"type": {
"coding": [
{
"system": "http://loinc.org",
"code": "34108-1",
"display": "Outpatient Note"
}
]
},
"category": [
{
"coding": [
{
"system": "http://ihe.net/xds/connectathon/classCodes",
"code": "History and Physical",
"display": "History and Physical"
}
]
}
],
"subject": {
"reference": "Patient/xcda"
},
"encounter": [
{
"reference": "Encounter/xcda"
}
],
"event": [
{
"coding": [
{
"system": "http://ihe.net/xds/connectathon/eventCodes",
"code": "T-D8200",
"display": "Arm"
}
]
}
],
"facilityType": {
"coding": [
{
"system": "http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes",
"code": "Outpatient",
"display": "Outpatient"
}
]
},
"practiceSetting": {
"coding": [
{
"system": "http://www.ihe.net/xds/connectathon/practiceSettingCodes",
"code": "General Medicine",
"display": "General Medicine"
}
]
},
"period": {
"start": "2004-12-23T08:00:00+11:00",
"end": "2004-12-23T08:01:00+11:00"
},
"date": "2005-12-24T09:43:41+11:00",
"author": [
{
"reference": "Practitioner/xcda1"
},
{
"reference": "#a2"
}
],
"attester": [
{
"mode": "official",
"party": {
"reference": "Organization/f001"
}
}
],
"custodian": {
"reference": "Organization/f001"
},
"relatesTo": [
{
"code": "appends",
"target": {
"reference": "DocumentReference/example"
}
}
],
"description": "Physical",
"securityLabel": [
{
"coding": [
{
"system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
"code": "V",
"display": "very restricted"
}
]
}
],
"content": [
{
"attachment": {
"contentType": "application/hl7-v3+xml",
"language": "en-US",
"url": "http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510",
"size": "3654",
"hash": "2jmj7l5rSw0yVb/vlWAYkK/YBwk=",
"title": "Physical",
"creation": "2005-12-24T09:35:00+11:00"
},
"format": {
"system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
"code": "urn:ihe:pcc:handp:2008",
"display": "History and Physical Specification"
},
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7"
}
}
],
"sourcePatientInfo": {
"reference": "Patient/xcda"
},
"related": [
{
"reference": "Patient/xcda",
"identifier": {
"system": "urn:ietf:rfc:3986",
"value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"
}
}
]
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.