A reference to a document.

Usually, this is used for documents other than those defined by FHIR.

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 document.

The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g., for a DICOM standard document a 64 character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form oid^extension, where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

CDA Document Id extension and root.

Other identifiers associated with the document, including version independent, source record and workflow related identifiers.

Other identifiers can also include Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDS Workflow Instance Identifiers.

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).

The type code specifies the precise type of document from the user perspective. 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.).

Key metadata element describing the document, used in searching/filtering.

The class code specifying the high-level use classification of the document type (e.g., Report, Summary, Images, Treatment Plan, Patient Preferences, Workflow).

Helps humans to assess whether the document is of interest when viewing an list of documents.

An identifier that identifies the the document encoding, structure and template that the document conforms to beyond the base format indicated in the mimeType.

Helps the processing. Usually is a URN that identifies. For IHE defined Document Content profiles this is a urn issued by IHE.

Identifies who is responsible for adding the information to the document.

Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Identifies the logical organization to go to find the current version, where to report issues, etc. This is different from the physical location of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

A reference to a domain or server that manages policies under which the document is accessed and/or made available.

Which person or organization authenticates that this document is valid.

Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.

When the document was created.

Creation time is used for tracking, organizing versions and searching. This is the creation time of the document, not the source material on which it is based.

When the document reference was created.

Referencing/indexing time is used for tracking, organizing versions and searching.

The status of this document reference.

This is the status of the DocumentReference object, which might be independent from the docStatus.

The status of the underlying document.

The document that is pointed to might be in various lifecycle states.

Relationships that this document has with other document references that already exist.

The type of relationship that this document has with anther document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The target document of this relationship.

Human-readable description of the source document. This is sometimes known as the "title".

Helps humans to assess whether the document is of interest.

What the document is about, rather than a terse summary of the document. It is commonly the case that records do not have a title and are collectively referred to by the display name of Record code (e.g. a "consultation" or "progress note").

A set of Security-Tag codes specifying the level of privacy/security of the Document.

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. • [1…1] Confidentiality Security Classification Label Field • [0…] Sensitivity Security Category Label Field • [0…] Compartment Security Category Label Field • [0…] Integrity Security Category Label Field • [0…] Handling Caveat Security Category Field In the HL7 Healthcare Privacy and Security Classification System In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

The document or url to the document along with critical metadata to prove content has integrity.

The clinical context in which the document was prepared.

These values are primarily added to help with searching for interesting/relevant documents.

This 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" act.

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

The time period over which the service that is described by the document was provided.

The kind of facility where the patient was seen.