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 XML (canonical form + also see XML Format Specification)
Generic example (id = "example")
<?xml version="1.0" encoding="UTF-8"?> <DocumentReference xmlns="http://hl7.org/fhir"> <id value="example"/> <!-- Many XDS systems do not trak any id for the author. When systems don't do this, the only option is for the author information to be contained in the Document Reference --> <text> <status value="generated"/> <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> </text> <contained> <Practitioner> <id value="a2"/> <name> <family value="Smitty"/> <given value="Gerald"/> </name> </Practitioner> </contained> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"/> </identifier> <status value="current"/> <docStatus value="preliminary"/> <type> <coding> <system value="http://loinc.org"/> <code value="34108-1"/> <display value="Outpatient Note"/> </coding> </type> <category> <coding> <system value="http://ihe.net/xds/connectathon/classCodes"/> <code value="History and Physical"/> <display value="History and Physical"/> </coding> </category> <subject> <reference value="Patient/xcda"/> </subject> <encounter> <reference value="Encounter/xcda"/> </encounter> <event> <coding> <system value="http://ihe.net/xds/connectathon/eventCodes"/> <code value="T-D8200"/> <display value="Arm"/> </coding> </event> <facilityType> <coding> <system value="http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes"/> <code value="Outpatient"/> <display value="Outpatient"/> </coding> </facilityType> <practiceSetting> <coding> <system value="http://www.ihe.net/xds/connectathon/practiceSettingCodes"/> <code value="General Medicine"/> <display value="General Medicine"/> </coding> </practiceSetting> <period> <start value="2004-12-23T08:00:00+11:00"/> <end value="2004-12-23T08:01:00+11:00"/> </period> <date value="2005-12-24T09:43:41+11:00"/> <author> <reference value="Practitioner/xcda1"/> </author> <author> <reference value="#a2"/> </author> <attester> <mode value="official"/> <party> <reference value="Organization/f001"/> </party> </attester> <custodian> <reference value="Organization/f001"/> </custodian> <relatesTo> <code value="appends"/> <target> <reference value="DocumentReference/example"/> </target> </relatesTo> <description value="Physical"/> <securityLabel> <coding> <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/> <code value="V"/> <display value="very restricted"/> </coding> </securityLabel> <content> <attachment> <contentType value="application/hl7-v3+xml"/> <language value="en-US"/> <url value="http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510"/> <size value="3654"/> <hash value="2jmj7l5rSw0yVb/vlWAYkK/YBwk="/> <title value="Physical"/> <creation value="2005-12-24T09:35:00+11:00"/> </attachment> <format> <system value="urn:oid:1.3.6.1.4.1.19376.1.2.3"/> <code value="urn:ihe:pcc:handp:2008"/> <display value="History and Physical Specification"/> </format> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7"/> </identifier> </content> <sourcePatientInfo> <reference value="Patient/xcda"/> </sourcePatientInfo> <related> <reference value="Patient/xcda"/> <identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"/> </identifier> </related> </DocumentReference>
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.