A reference to a document. document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.

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

Document identifier as Business identifiers assigned to this document reference by the source of performer and/or other systems. These identifiers remain constant as the document. This identifier resource is specific updated and propagates from server to this version of server.

Document identifiers usually assigned by the source of the document, or other business identifiers such as XDS DocumentEntry.uniqueId and DocumentEntry.entryUUID. These identifiers are specific to this instance of the document.

The structure and format of this Id shall identifier would be consistent with the specification corresponding to the formatCode attribute. format of the document. (e.g. for a DICOM standard document document, a 64-character numeric UID, UID; for an HL7 CDA format a serialization of format, the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the extension).

An explicitly assigned identifier of a 16 UTF-8 char max. If variation of the OID is coded without content in the extension then DocumentReference.

CDA Document Id extension While each resource, including the DocumentReference itself, has its own version identifier, this is a formal identifier for the logical version of the DocumentReference as a whole. It would remain constant if the resources were moved to a new server, and root. all got new individual resource versions, for example.

Other identifiers associated with A procedure that is fulfilled in whole or in part by the document, including version independent identifiers. creation of this media.

Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

The status current state of this the document reference.

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

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

The status of the underlying document.

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

Imaging modality used. This may include both acquisition and non-acquisition modalities.

Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Key metadata element describing the document, used in searching/filtering. document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

Key metadata element describing the the category or classification of the document. This is a metadata field from XDS/MHD . broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a 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).

When the The Encounter during which this document reference was created. created or to which the creation of this record is tightly associated.

Links the document reference to the Encounter context. May also affect access control.

Creation time is used for tracking, organizing versions and searching. This is will typically be the creation time encounter the document reference was created during, but some document references may be initiated prior to or after the official completion of an encounter but still be tied to the document, not context of the source material on which it is based. encounter (e.g. pre-admission lab tests).

Referencing/indexing time This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is used for tracking, organizing versions inherent in the type Code, such as a "History and searching. Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Not necessarily who did An event can further specialize the actual data entry (i.e. typist) it act inherent in or who 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 source (informant). values inherent in the class or type elements as such a conflict would create an ambiguous situation.

Which person or organization authenticates that Any other resource this document reference was created or to which the creation of this record is valid. tightly associated.

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 Use only for references not covered by the legal Authenticator. other elements.

Identifies the organization or group who is responsible for ongoing maintenance of and access to The anatomic structures included in 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 The kind of facility where the document, which host may be delegated to the management of some other organization. patient was seen.

The type of relationship that this document has with anther document. This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

If this document appends another document, then the document cannot This element should be fully understood without also accessing based on a coarse classification system for the referenced document. class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

The target time period over which the service that is described by the document of this relationship. was provided.

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

What the document is about, rather than a terse summary of the document. It Referencing/indexing time is commonly the case that records do not have a title used for tracking, organizing versions and are collectively referred to by searching. Provide the display name of Record code (e.g. a "consultation" or "progress note"). most precise timestamp available.

A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of Identifies who is responsible for adding the "reference" information to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on document.

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Using Group is only allowed in the circumstance where the group represents a family or a household, and should not represent groups of Practitioners.

Use A participant who has authenticated the accuracy of the Health Care Privacy/Security Classification (HCS) system document.

Identifies responsibility for the accuracy of the document content.

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. 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. Only list each attester once.

The document and format referenced. There may be multiple content element repetitions, each with a different format. type of attestation the authenticator offers.

Indicates the level of authority of the attestation.

The document or URL of When the document along with critical metadata to prove content has integrity. was attested by the party.

Identifies when the information in the document was deemed accurate. (Things may have changed since then.).

An identifier of the document encoding, structure, and template that Who attested the document conforms to beyond the base format indicated in the mimeType. specified way.

Identifies who has taken on the responsibility for accuracy of the document content.

Note that while IHE mostly issues URNs for format types, not all documents can be identified by Using Group is only allowed in the circumstance where the group represents a URI. family or a household, and should not represent groups of Practitioners.

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

These values are primarily added Identifies the logical organization (software system, vendor, or department) to help with searching for interesting/relevant documents. go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

Describes the clinical encounter or type of care Relationships that the this document content is associated with. has with other document references that already exist.

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

This list The type 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. relationship that this document has with anther document.

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 this document appends another document, then the values inherent in document cannot be fully understood without also accessing the class or type elements as such a conflict would create an ambiguous situation. referenced document.

The time period over which the service that is described by the target document was provided. of this relationship.

The kind Human-readable description of facility where the patient was seen. source document.

Helps humans to assess whether the document is of interest.

What the document is about, a terse summary of the document.

This property A set of Security-Tag codes specifying the level of privacy/security of the Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the data elements in DocumentReference, while DocumentReference.securityLabel contains the security labels for the document the reference refers to. The distinction recognizes that the document may convey specifics contain sensitive information, while the DocumentReference is metadata about the practice setting where document and thus might not be as sensitive as the content was created, often reflecting document. For example: a psychotherapy episode may contain highly sensitive information, while the clinical specialty. metadata may simply indicate that some episode happened.

This is an important piece Use of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

The value set for this content confidentiality codes can carry multiple vocabulary items. HL7 has developed an example binding because it is understanding of security and privacy tags that might be desirable in a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR Document Sharing environment, called HL7 Healthcare Privacy and XDM for Direct Messaging Specification, Version 1), Security Classification System (HCS). The following specification is recommended but not mandated, as well the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * the XDS Connect-a-thon practiceSettingCode. Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

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 Patient Information as known when document and format referenced. If there are multiple content element repetitions, these must all represent the same document was published. May be a reference to a version specific, in different format, or contained. attachment metadata.

Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

Related identifiers The document or resources associated with URL of the DocumentReference. document along with critical metadata to prove content has integrity.

Related An identifier to this DocumentReference. If both id of the document constraints, encoding, structure, and ref are present they shall refer template that the document conforms to beyond the same thing. base format indicated in the mimeType.

Order numbers, accession numbers, XDW workflow numbers. Note that IHE often issues URNs for formatCode codes, not all documents can be identified by a URI.

For FHIR content, .profile should indicate the structureDefinition profile canonical URI(s) that the content complies with.

Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thing. Code|uri|canonical.