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6.4 Resource DocumentReference - Content

A reference to a document.

6.4.3 Resource Content

This resource is referenced by [DocumentManifest]

<DocumentReference xmlns="http://hl7.org/fhir"> 
 <!-- from Resource: extension, modifierExtension, language, text, and contained -->
 <masterIdentifier><!-- 1..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 1..1 Resource(Patient|Practitioner|Group|Device) 
     Who|what is the subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept What kind of document this is (LOINC if possible) --></type>
 <class><!-- 0..1 CodeableConcept Categorization of Document --></class>
 <author><!-- 1..* Resource(Practitioner|Device|Patient|RelatedPerson) 
     Who and/or what authored the document --></author>
 <custodian><!-- 0..1 Resource(Organization) Org which maintains the document --></custodian>
 <policyManager value="[uri]"/><!-- 0..1 Manages access policies for the document -->
 <authenticator><!-- 0..1 Resource(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!-- 1..1 current | superceded | entered in error --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 Resource(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[string]"/><!-- 0..1 Human-readable description (title) -->
 <confidentiality><!-- 0..* CodeableConcept Sensitivity of source document --></confidentiality>
 <primaryLanguage value="[code]"/><!-- 0..1 The marked primary language for the document -->
 <mimeType value="[code]"/><!-- 1..1 Mime type, + maybe character encoding -->
 <format value="[uri]"/><!-- 0..* Format/content rules for the document -->
 <size value="[integer]"/><!-- 0..1 Size of the document in bytes -->
 <hash value="[string]"/><!-- 0..1 HexBinary representation of SHA1 -->
 <location value="[uri]"/><!--  0..1 Where to access the document -->
 <service>  <!--  0..1 If access is not fully described by location -->
  <type><!-- 1..1 CodeableConcept Type of service (i.e. XDS.b) --></type>
  <address value="[string]"/><!-- 0..1 Where service is located (usually a URL) -->
  <parameter>  <!-- 0..* Service call parameters -->
   <name value="[string]"/><!-- 1..1 Parameter name in service call -->
   <value value="[string]"/><!-- 0..1 Parameter value for the name -->
  </parameter>
 </service>
 <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>
 </context>
</DocumentReference>

Alternate definitions: Schema/Schematron, Resource Profile

6.4.3.1 Terminology Bindings

6.4.3.2 Constraints

• Inv-1: A location or a service (or both) SHALL be provided (xpath: exists(f:location) or exists(f:service))

6.4.4 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

6.4.4.1 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.

6.4.4.2 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:

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:

6.4.5 Search Parameters

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