Release 5 FHIR CI-Build

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See the Directory of published versions icon . Page versions: R5 R4B R4 R3 R2

10.2 Resource DocumentReference - Content

Responsible Owner: Orders and Observations icon Work Group Maturity Level : 4   Trial Use Normative Security Category : Not Classified Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

A reference to a 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.

10.2.1 Scope and Usage

A DocumentReference resource is used to index a document, clinical note, and other binary objects such as a photo, video, or audio recording, including those resulting from diagnostic or care provision procedures, to make them available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be presented to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type and that conforms to this definition.

Typically, DocumentReference resources are used in document indexing systems, such as IHE XDS icon and as profiled in IHE Mobile Access to Health Documents icon .

DocumentReference contains metadata, inline content or direct references to documents such as:

  • CDA icon documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents icon , Scanned Paper, and digital records of faxes
  • Clinical Notes in various forms
  • Image files (e.g., JPEG, GIF, TIFF)
  • Video files (e.g., MP4, WMV)
  • Audio files (e.g., WAV, MP3)
  • Non-Standard formats (e.g., CSV, RTF, WORD)
  • Other kinds of documents, such as records of prescriptions or immunizations

10.2.2 Boundaries and Relationships

This resource captures data that might not be in FHIR format. The document can be any object (e.g. file), and is not limited to the formal HL7 definitions of Document . This resource may be a report with unstructured text or a report that is not expressed in a DiagnosticReport. DiagnosticReport . The DiagnosticReport is appropriate to reflect a set of discrete results (Observations) and associated contextual details for a specific report, and within those results any further structure within the Observation instances. The DocumentReference resource may be an Observation whose value is audio, video or image data. This resource is the preferred representation of such forms of information as it exposes the metadata relevant for interpreting the information. There is some overlap potential such as a scan of a CBC report that can either be referenced by way of a DocumentReference, DocumentReference , or included in a DiagnosticReport as a presentedForm together with the structured, discrete data. In some cases, a single in-system entity may be represented as both resources if they provide relevant metadata or workflow-specific attributes. Specific implementation guides would further clarify when one which approach is more appropriate than another. appropriate.

This resource is able to contain medical images in a DICOM format. These images may also be made accessible through an ImagingStudy or ImagingSelection resource, which provides a direct reference to the image to a WADO-RS server. For such images, the WADO-RS framework is a preferred method for representing the images - the WADO-RS service may include rendering the image with annotations and display parameters from an associated DICOM presentation state, for instance. On the other hand, the DocumentReference resource allows for a robust transfer of an image across boundaries where the WADO-RS service is not available. For this reason, medical images can also be represented in a DocumentReference resource, but the DocumentReference.content.attachment.url should provide a reference to a source WADO-RS service for the image.

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. DocumentReference is intended for general references to any type of media file including assembled documents.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource , or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet, RetrieveDocumentSet icon, or a DICOM WADO-RS exchange, or an HL7 V2 icon message query - though the way each of these service calls works must be specified in some external standard or other documentation.

A DocumentReference describes some other document. This means that there are two sets of provenance information relevant here: the provenance of the document, and the provenance of the document reference. Sometimes, the provenance information is closely related, as when the document producer also produces the document reference, but in other workflows, the document reference is generated later by other actors. In the DocumentReference resource, the meta content refers to the provenance of the reference itself, while the content described below concerns the document it references. Like all resources, there is overlap between the information in the resource directly, and in the general Provenance resource. This is discussed as part of the description of the Provenance resource .

10.2.3 References to this Resource

10.2.4 Resource Content

Structure

Context of 0..*
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . DocumentReference TU N DomainResource A reference to a document
+ Warning: facilityType SHALL only be present if context is not an encounter
+ Warning: practiceSetting SHALL only be present if context is not present

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifiers for the document

. . . version Σ 0..1 string An explicitly assigned identifer identifier of a variation of the content in the DocumentReference
. . . basedOn 0..* Reference ( Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription ) Procedure that caused this media to be created

. . . docStatus ?! Σ 0..1 code registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: Composition Status ( Required )
. . . modality Σ 0..* CodeableConcept Imaging modality used
Binding: Modality icon ( Extensible )

. . . type Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: FHIR Document Type Codes ( Preferred )
. . . category Σ 0..* CodeableConcept Categorization of document
Binding: Referenced Item Category Value Set ( Example )

. . . subject Σ 0..1 Reference ( Any ) Who/what is the subject of the document
. . . context Σ C 0..* Reference ( Appointment | Encounter | EpisodeOfCare ) Encounter the document content reference is part of

. . . event 0..* CodeableReference () ( Any ) Main clinical acts documented
Binding: v3 Code System ActCode icon ( Example )

. . . bodySite related 0..* Σ Reference ( Any ) Related identifiers or resources associated with the document reference

. . . bodyStructure Σ 0..* CodeableReference ( BodyStructure ) Body part structure included
Binding: SNOMED CT Body Structures ( Example )

. . . facilityType C 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set ( Example )
. . . practiceSetting C 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set ( Example )
. . . period Σ 0..1 Period Time of service that is being documented
. . . date Σ 0..1 instant dateTime When this document reference was created
. . . author Σ 0..* Reference ( Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam | Group ) Who and/or what authored the document

. . . attester 0..* BackboneElement Attests to accuracy of the document

. . . . mode 1..1 CodeableConcept personal | professional | legal | official
Binding: Composition Attestation Mode ( Preferred )
. . . . time 0..1 dateTime When the document was attested
. . . . party 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization | Group ) Who attested the document
. . . custodian 0..1 Reference ( Organization ) Organization which maintains the document
. . . relatesTo Σ 0..* BackboneElement Relationships to other documents

. . . . code Σ 1..1 CodeableConcept The relationship type with another document
Binding: Document Relationship Type ( Extensible )
. . . . target Σ 1..1 Reference ( DocumentReference ) Target of the relationship
. . . description Σ 0..1 markdown Human-readable description
. . . securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: Example set of Security Labels ( Example )

. . . content Σ 1..* BackboneElement Document referenced

. . . . attachment Σ 1..1 Attachment Where to access the document
. . . . profile Σ 0..* BackboneElement Content profile rules for the document

. . . . . value[x] Σ 1..1 Code|uri|canonical
Binding: HL7 ValueSet of Format Codes for use with Document Sharing icon ( Preferred )
. . . . . . valueCoding Coding
. . . . . . valueUri uri
. . . . . . valueCanonical canonical ()

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

DocumentReference ( DomainResource ) Other business Business identifiers associated with assigned to this document reference by the document, including version independent performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] An explicitly assigned identifer identifier of a variation of the content in the DocumentReference version : string [0..1] A procedure that is fulfilled in whole or in part by the creation of this media basedOn : Reference [0..*] « Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription » The status current state of this the document reference (this element modifies the meaning of other elements) status : code [1..1] « null (Strength=Required) DocumentReferenceStatus ! » The status of the underlying document (this element modifies the meaning of other elements) docStatus : code [0..1] « null (Strength=Required) CompositionStatus ! » Imaging modality used. This may include both acquisition and non-acquisition modalities modality : CodeableConcept [0..*] « null (Strength=Extensible) Modality + » 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 type : CodeableConcept [0..1] « null (Strength=Preferred) FHIRDocumentTypeCodes ? » 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 category : CodeableConcept [0..*] « null (Strength=Example) ReferencedItemCategoryValueSet ?? » 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) subject : Reference [0..1] « Any » Describes the clinical encounter The Encounter during which this document reference was created or type of care that to which the document content creation of this record is tightly associated with context : Reference [0..*] « Appointment | Encounter | EpisodeOfCare » « This element has or is affected by some invariants C » 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 type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act event : CodeableReference [0..*] « Any ; null (Strength=Example) ActCode ?? » Any other resource this document reference was created or to which the creation of this record is tightly associated related : Reference [0..*] « Any » The anatomic structures included in the document bodySite bodyStructure : CodeableReference [0..*] « BodyStructure ; Codes describing anatomical locations. body structures. May include laterality. (Strength=Example) SNOMEDCTBodyStructures ?? » The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) FacilityTypeCodeValueSet ?? » « This element has or is affected by some invariants C » This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty practiceSetting : CodeableConcept [0..1] « null (Strength=Example) PracticeSettingCodeValueSet ?? » « This element has or is affected by some invariants C » The time period over which the service that is described by the document was provided period : Period [0..1] When the document reference was created date : instant dateTime [0..1] Identifies who is responsible for adding the information to the document author : Reference [0..*] « Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam | Group » Identifies the organization or group who is responsible for ongoing maintenance of and access to the document custodian : Reference [0..1] « Organization » Human-readable description of the source document description : markdown [0..1] 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 contain sensitive information, while the DocumentReference is metadata about the document and thus might not be as sensitive as the document. For example: a psychotherapy episode may contain highly sensitive information, while the metadata may simply indicate that some episode happened securityLabel : CodeableConcept [0..*] « null (Strength=Example) SecurityLabelExamples ?? » Attester The type of attestation the authenticator offers mode : CodeableConcept [1..1] « null (Strength=Preferred) CompositionAttestationMode ? » When the document was attested by the party time : dateTime [0..1] Who attested the document in the specified way party : Reference [0..1] « Patient | RelatedPerson | Practitioner | PractitionerRole | Organization | Group » RelatesTo The type of relationship that this document has with anther document code : CodeableConcept [1..1] « null (Strength=Extensible) DocumentRelationshipType + » The target document of this relationship target : Reference [1..1] « DocumentReference » Content The document or URL of the document along with critical metadata to prove content has integrity attachment : Attachment [1..1] Profile Code|uri|canonical value[x] : DataType [1..1] « Coding | uri | canonical ; null (Strength=Preferred) HL7FormatCodes ? » A participant who has authenticated the accuracy of the document attester [0..*] Relationships that this document has with other document references that already exist relatesTo [0..*] An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType profile [0..*] The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata content [1..*]

XML Template 

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <

 <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier>
 <version value="[string]"/><!-- 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference -->

 <basedOn><!-- 0..* Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   |
   </basedOn>
 <
 <

   EnrollmentRequest|MedicationRequest|NutritionOrder|RequestOrchestration|
   ServiceRequest|VisionPrescription) Procedure that caused this media to be created --></basedOn>
 <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error -->
 <docStatus value="[code]"/><!-- 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown -->

 <modality><!-- 0..* CodeableConcept Imaging modality used icon --></modality>
 <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <category><!-- 0..* CodeableConcept Categorization of document --></category>
 <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject>
 <</context>
 <</event>
 <</bodySite>

 <context><!-- I 0..* Reference(Appointment|Encounter|EpisodeOfCare) Encounter the document reference is part of --></context>
 <event><!-- 0..* CodeableReference(Any) Main clinical acts documented icon --></event>
 <related><!-- 0..* Reference(Any) Related identifiers or resources associated with the document reference --></related>
 <bodyStructure><!-- 0..* CodeableReference(BodyStructure) Body structure included --></bodyStructure>

 <facilityType><!-- I 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
 <practiceSetting><!-- I 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
 <period><!-- 0..1 Period Time of service that is being documented --></period>
 <
 <|
   </author>

 <date value="[dateTime]"/><!-- 0..1 When this document reference was created -->
 <author><!-- 0..* Reference(CareTeam|Device|Group|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) Who and/or what authored the document --></author>
 <attester>  <!-- 0..* Attests to accuracy of the document -->
  <mode><!-- 1..1 CodeableConcept personal | professional | legal | official --></mode>
  <time value="[dateTime]"/><!-- 0..1 When the document was attested -->
  <|
    </party>

  <party><!-- 0..1 Reference(Group|Organization|Patient|Practitioner|
    PractitionerRole|RelatedPerson) Who attested the document --></party>
 </attester>
 <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document --></custodian>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code><!-- 1..1 CodeableConcept The relationship type with another document --></code>
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[markdown]"/><!-- 0..1 Human-readable description -->
 <</securityLabel>

 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>

 <content>  <!-- 1..* Document referenced -->
  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <profile>  <!-- 0..* Content profile rules for the document -->
   <</value[x]>

   <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical icon --></value[x]>

  </profile>
 </content>
</DocumentReference>

JSON Template 

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "

  "identifier" : [{ Identifier }], // Business identifiers for the document
  "version" : "<string>", // An explicitly assigned identifier of a variation of the content in the DocumentReference

  "basedOn" : [{ Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   |
   
  "
  "

   EnrollmentRequest|MedicationRequest|NutritionOrder|RequestOrchestration|
   ServiceRequest|VisionPrescription) }], // Procedure that caused this media to be created
  "status" : "<code>", // R!  current | superseded | entered-in-error
  "docStatus" : "<code>", // registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  "modality" : [{ CodeableConcept }], // Imaging modality used icon
  "type" : { CodeableConcept }, // Kind of document (LOINC if possible)
  "category" : [{ CodeableConcept }], // Categorization of document
  "subject" : { Reference(Any) }, // Who/what is the subject of the document
  "
  "
  "

  "context" : [{ Reference(Appointment|Encounter|EpisodeOfCare) }], // I Encounter the document reference is part of
  "event" : [{ CodeableReference(Any) }], // Main clinical acts documented icon
  "related" : [{ Reference(Any) }], // Related identifiers or resources associated with the document reference
  "bodyStructure" : [{ CodeableReference(BodyStructure) }], // Body structure included

  "facilityType" : { CodeableConcept }, // I Kind of facility where patient was seen
  "practiceSetting" : { CodeableConcept }, // I Additional details about where the content was created (e.g. clinical specialty)
  "period" : { Period }, // Time of service that is being documented
  "
  "|
   

  "date" : "<dateTime>", // When this document reference was created
  "author" : [{ Reference(CareTeam|Device|Group|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) }], // Who and/or what authored the document
  "attester" : [{ // Attests to accuracy of the document
    "mode" : { CodeableConcept }, // R!  personal | professional | legal | official
    "time" : "<dateTime>", // When the document was attested
    "|
    

    "party" : { Reference(Group|Organization|Patient|Practitioner|
    PractitionerRole|RelatedPerson) } // Who attested the document
  }],
  "custodian" : { Reference(Organization) }, // Organization which maintains the document
  "relatesTo" : [{ // Relationships to other documents
    "code" : { CodeableConcept }, // R!  The relationship type with another document
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<markdown>", // Human-readable description
  "

  "securityLabel" : [{ CodeableConcept }], // Document security-tags

  "content" : [{ // R!  Document referenced
    "attachment" : { Attachment }, // R!  Where to access the document
    "profile" : [{ // Content profile rules for the document
      // value[x]: Code|uri|canonical. One of these 3:
      "valueCoding" : { Coding },
      "valueUri" : "<uri>",
      "valueCanonical" : "<canonical>"
    }]
  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:DocumentReference;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifiers for the document
  fhir:version [ string ] ; # 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference

  fhir:basedOn  ( [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract|
  |
  |
  
  fhir:
  fhir:

  CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest|MedicationRequest|
  NutritionOrder|RequestOrchestration|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Procedure that caused this media to be created
  fhir:status [ code ] ; # 1..1 current | superseded | entered-in-error
  fhir:docStatus [ code ] ; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  fhir:modality  ( [ CodeableConcept ] ... ) ; # 0..* Imaging modality used
  fhir:type [ CodeableConcept ] ; # 0..1 Kind of document (LOINC if possible)
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* Categorization of document
  fhir:subject [ Reference(Any) ] ; # 0..1 Who/what is the subject of the document
  fhir:
  fhir:
  fhir:

  fhir:context  ( [ Reference(Appointment|Encounter|EpisodeOfCare) ] ... ) ; # 0..* I Encounter the document reference is part of
  fhir:event  ( [ CodeableReference(Any) ] ... ) ; # 0..* Main clinical acts documented
  fhir:related  ( [ Reference(Any) ] ... ) ; # 0..* Related identifiers or resources associated with the document reference
  fhir:bodyStructure  ( [ CodeableReference(BodyStructure) ] ... ) ; # 0..* Body structure included

  fhir:facilityType [ CodeableConcept ] ; # 0..1 I Kind of facility where patient was seen
  fhir:practiceSetting [ CodeableConcept ] ; # 0..1 I Additional details about where the content was created (e.g. clinical specialty)
  fhir:period [ Period ] ; # 0..1 Time of service that is being documented
  fhir:
  fhir:

  fhir:date [ dateTime ] ; # 0..1 When this document reference was created
  fhir:author  ( [ Reference(CareTeam|Device|Group|Organization|Patient|Practitioner|PractitionerRole|
  RelatedPerson) ] ... ) ; # 0..* Who and/or what authored the document
  fhir:attester ( [ # 0..* Attests to accuracy of the document
    fhir:mode [ CodeableConcept ] ; # 1..1 personal | professional | legal | official
    fhir:time [ dateTime ] ; # 0..1 When the document was attested
    fhir:

    fhir:party [ Reference(Group|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who attested the document

  ] ... ) ;
  fhir:custodian [ Reference(Organization) ] ; # 0..1 Organization which maintains the document
  fhir:relatesTo ( [ # 0..* Relationships to other documents
    fhir:code [ CodeableConcept ] ; # 1..1 The relationship type with another document
    fhir:target [ Reference(DocumentReference) ] ; # 1..1 Target of the relationship
  ] ... ) ;
  fhir:description [ markdown ] ; # 0..1 Human-readable description
  fhir:securityLabel  ( [ CodeableConcept ] ... ) ; # 0..* Document security-tags
  fhir:content ( [ # 1..* Document referenced
    fhir:attachment [ Attachment ] ; # 1..1 Where to access the document
    fhir:profile ( [ # 0..* Content profile rules for the document
      # value[x] : 1..1 Code|uri|canonical. One of these 3
        fhir:value [  a fhir:Coding ; Coding ]
        fhir: ]
        fhir: ]

        fhir:value [  a fhir:Uri ; uri ]
        fhir:value [  a fhir:Canonical ; canonical ]

    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

DocumentReference
DocumentReference.version
  • Added Element
DocumentReference.basedOn
  • Added Element
DocumentReference.docStatus
  • Remove code preliminary
  • Add codes registered , partial , corrected , appended , cancelled , deprecated , unknown
  • Now marked as Modifier
DocumentReference.modality
  • Added Element
DocumentReference.subject
  • Type Reference: Added Target Type Resource
  • Type Reference: Removed Target Types Patient, Practitioner, Group, Device
DocumentReference.context
  • Max Cardinality changed from 1 to *
  • Type changed from BackboneElement to Reference(Appointment | Encounter | EpisodeOfCare)
DocumentReference.event
  • Added Element
DocumentReference.bodySite DocumentReference.related
  • Added Element
DocumentReference.bodyStructure
  • Added Element
DocumentReference.facilityType
  • Added Element
DocumentReference.practiceSetting
  • Added Element
DocumentReference.period
  • Added Element
DocumentReference.date
  • Type changed from instant to dateTime
DocumentReference.author
  • Type Reference: Added Target Type CareTeam Types CareTeam, Group
DocumentReference.attester
  • Added Element
DocumentReference.attester.mode
  • Added Mandatory Element
DocumentReference.attester.time
  • Added Element
DocumentReference.attester.party
  • Added Element
DocumentReference.relatesTo.code
  • Type changed from code to CodeableConcept
  • Change binding strength from required to extensible
DocumentReference.description
  • Type changed from string to markdown
DocumentReference.securityLabel
  • Remove Binding `http://hl7.org/fhir/ValueSet/security-labels` (extensible)
DocumentReference.content.profile
  • Added Element
DocumentReference.content.profile.value[x]
  • Added Mandatory Element
DocumentReference.masterIdentifier
  • Deleted (-> identifier)
DocumentReference.authenticator
  • Deleted (-> attester)
DocumentReference.content.format
  • Deleted (-> content.profile)
DocumentReference.context.encounter
  • Deleted (-> context)
DocumentReference.context.event
  • Deleted (-> event)
DocumentReference.context.period
  • Deleted (-> period)
DocumentReference.context.facilityType
  • Deleted (-> facilityType)
DocumentReference.context.practiceSetting
  • Deleted (-> practiceSetting)
DocumentReference.context.sourcePatientInfo
  • Deleted (-> use extension http://hl7.org/fhir/StructureDefinition/documentreference-sourcepatient)
DocumentReference.context.related
  • Deleted (-> basedOn)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R4 <--> R5 Conversion Maps (status = See Conversions Summary .)

Structure

Context of
Name Flags Card. Type Description & Constraints      Filter: Filters doco
. . DocumentReference TU N DomainResource A reference to a document
+ Warning: facilityType SHALL only be present if context is not an encounter
+ Warning: practiceSetting SHALL only be present if context is not present

Elements defined in Ancestors: id , meta , implicitRules , language , text , contained , extension , modifierExtension
. . . identifier Σ 0..* Identifier Business identifiers for the document

. . . version Σ 0..1 string An explicitly assigned identifer identifier of a variation of the content in the DocumentReference
. . . basedOn 0..* Reference ( Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription ) Procedure that caused this media to be created

. . . docStatus ?! Σ 0..1 code registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Binding: Composition Status ( Required )
. . . modality Σ 0..* CodeableConcept Imaging modality used
Binding: Modality icon ( Extensible )

. . . type Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
Binding: FHIR Document Type Codes ( Preferred )
. . . category Σ 0..* CodeableConcept Categorization of document
Binding: Referenced Item Category Value Set ( Example )

. . . subject Σ 0..1 Reference ( Any ) Who/what is the subject of the document
. . . context Σ C 0..* Reference ( Appointment | Encounter | EpisodeOfCare ) Encounter the document content reference is part of

. . . event 0..* CodeableReference () ( Any ) Main clinical acts documented
Binding: v3 Code System ActCode icon ( Example )

. . . bodySite related 0..* Σ Reference ( Any ) Related identifiers or resources associated with the document reference

... bodyStructure Σ 0..* CodeableReference ( BodyStructure ) Body part structure included
Binding: SNOMED CT Body Structures ( Example )

. . . facilityType C 0..1 CodeableConcept Kind of facility where patient was seen
Binding: Facility Type Code Value Set ( Example )
. . . practiceSetting C 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: Practice Setting Code Value Set ( Example )
. . . period Σ 0..1 Period Time of service that is being documented
. . . date Σ 0..1 instant dateTime When this document reference was created
. . . author Σ 0..* Reference ( Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam | Group ) Who and/or what authored the document

. . . attester 0..* BackboneElement Attests to accuracy of the document

. . . . mode 1..1 CodeableConcept personal | professional | legal | official
Binding: Composition Attestation Mode ( Preferred )
. . . . time 0..1 dateTime When the document was attested
. . . . party 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization | Group ) Who attested the document
. . . custodian 0..1 Reference ( Organization ) Organization which maintains the document
. . . relatesTo Σ 0..* BackboneElement Relationships to other documents

. . . . code Σ 1..1 CodeableConcept The relationship type with another document
Binding: Document Relationship Type ( Extensible )
. . . . target Σ 1..1 Reference ( DocumentReference ) Target of the relationship
. . . description Σ 0..1 markdown Human-readable description
. . . securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: Example set of Security Labels ( Example )

. . . content Σ 1..* BackboneElement Document referenced

. . . . attachment Σ 1..1 Attachment Where to access the document
. . . . profile Σ 0..* BackboneElement Content profile rules for the document

. . . . . value[x] Σ 1..1 Code|uri|canonical
Binding: HL7 ValueSet of Format Codes for use with Document Sharing icon ( Preferred )
. . . . . . valueCoding Coding
. . . . . . valueUri uri
. . . . . . valueCanonical canonical ()

doco Documentation for this format icon

See the Extensions for this resource

UML Diagram ( Legend )

DocumentReference ( DomainResource ) Other business Business identifiers associated with assigned to this document reference by the document, including version independent performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server identifier : Identifier [0..*] An explicitly assigned identifer identifier of a variation of the content in the DocumentReference version : string [0..1] A procedure that is fulfilled in whole or in part by the creation of this media basedOn : Reference [0..*] « Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription » The status current state of this the document reference (this element modifies the meaning of other elements) status : code [1..1] « null (Strength=Required) DocumentReferenceStatus ! » The status of the underlying document (this element modifies the meaning of other elements) docStatus : code [0..1] « null (Strength=Required) CompositionStatus ! » Imaging modality used. This may include both acquisition and non-acquisition modalities modality : CodeableConcept [0..*] « null (Strength=Extensible) Modality + » 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 type : CodeableConcept [0..1] « null (Strength=Preferred) FHIRDocumentTypeCodes ? » 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 category : CodeableConcept [0..*] « null (Strength=Example) ReferencedItemCategoryValueSet ?? » 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) subject : Reference [0..1] « Any » Describes the clinical encounter The Encounter during which this document reference was created or type of care that to which the document content creation of this record is tightly associated with context : Reference [0..*] « Appointment | Encounter | EpisodeOfCare » « This element has or is affected by some invariants C » 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 type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act event : CodeableReference [0..*] « Any ; null (Strength=Example) ActCode ?? » Any other resource this document reference was created or to which the creation of this record is tightly associated related : Reference [0..*] « Any » The anatomic structures included in the document bodySite bodyStructure : CodeableReference [0..*] « BodyStructure ; Codes describing anatomical locations. body structures. May include laterality. (Strength=Example) SNOMEDCTBodyStructures ?? » The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) FacilityTypeCodeValueSet ?? » « This element has or is affected by some invariants C » This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty practiceSetting : CodeableConcept [0..1] « null (Strength=Example) PracticeSettingCodeValueSet ?? » « This element has or is affected by some invariants C » The time period over which the service that is described by the document was provided period : Period [0..1] When the document reference was created date : instant dateTime [0..1] Identifies who is responsible for adding the information to the document author : Reference [0..*] « Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam | Group » Identifies the organization or group who is responsible for ongoing maintenance of and access to the document custodian : Reference [0..1] « Organization » Human-readable description of the source document description : markdown [0..1] 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 contain sensitive information, while the DocumentReference is metadata about the document and thus might not be as sensitive as the document. For example: a psychotherapy episode may contain highly sensitive information, while the metadata may simply indicate that some episode happened securityLabel : CodeableConcept [0..*] « null (Strength=Example) SecurityLabelExamples ?? » Attester The type of attestation the authenticator offers mode : CodeableConcept [1..1] « null (Strength=Preferred) CompositionAttestationMode ? » When the document was attested by the party time : dateTime [0..1] Who attested the document in the specified way party : Reference [0..1] « Patient | RelatedPerson | Practitioner | PractitionerRole | Organization | Group » RelatesTo The type of relationship that this document has with anther document code : CodeableConcept [1..1] « null (Strength=Extensible) DocumentRelationshipType + » The target document of this relationship target : Reference [1..1] « DocumentReference » Content The document or URL of the document along with critical metadata to prove content has integrity attachment : Attachment [1..1] Profile Code|uri|canonical value[x] : DataType [1..1] « Coding | uri | canonical ; null (Strength=Preferred) HL7FormatCodes ? » A participant who has authenticated the accuracy of the document attester [0..*] Relationships that this document has with other document references that already exist relatesTo [0..*] An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType profile [0..*] The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata content [1..*]

XML Template 

<DocumentReference xmlns="http://hl7.org/fhir"> doco
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</identifier>
 <

 <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier>
 <version value="[string]"/><!-- 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference -->

 <basedOn><!-- 0..* Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   |
   </basedOn>
 <
 <

   EnrollmentRequest|MedicationRequest|NutritionOrder|RequestOrchestration|
   ServiceRequest|VisionPrescription) Procedure that caused this media to be created --></basedOn>
 <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error -->
 <docStatus value="[code]"/><!-- 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown -->

 <modality><!-- 0..* CodeableConcept Imaging modality used icon --></modality>
 <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <category><!-- 0..* CodeableConcept Categorization of document --></category>
 <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject>
 <</context>
 <</event>
 <</bodySite>

 <context><!-- I 0..* Reference(Appointment|Encounter|EpisodeOfCare) Encounter the document reference is part of --></context>
 <event><!-- 0..* CodeableReference(Any) Main clinical acts documented icon --></event>
 <related><!-- 0..* Reference(Any) Related identifiers or resources associated with the document reference --></related>
 <bodyStructure><!-- 0..* CodeableReference(BodyStructure) Body structure included --></bodyStructure>

 <facilityType><!-- I 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
 <practiceSetting><!-- I 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting>
 <period><!-- 0..1 Period Time of service that is being documented --></period>
 <
 <|
   </author>

 <date value="[dateTime]"/><!-- 0..1 When this document reference was created -->
 <author><!-- 0..* Reference(CareTeam|Device|Group|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) Who and/or what authored the document --></author>
 <attester>  <!-- 0..* Attests to accuracy of the document -->
  <mode><!-- 1..1 CodeableConcept personal | professional | legal | official --></mode>
  <time value="[dateTime]"/><!-- 0..1 When the document was attested -->
  <|
    </party>

  <party><!-- 0..1 Reference(Group|Organization|Patient|Practitioner|
    PractitionerRole|RelatedPerson) Who attested the document --></party>
 </attester>
 <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document --></custodian>
 <relatesTo>  <!-- 0..* Relationships to other documents -->
  <code><!-- 1..1 CodeableConcept The relationship type with another document --></code>
  <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target>
 </relatesTo>
 <description value="[markdown]"/><!-- 0..1 Human-readable description -->
 <</securityLabel>

 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>

 <content>  <!-- 1..* Document referenced -->
  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <profile>  <!-- 0..* Content profile rules for the document -->
   <</value[x]>

   <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical icon --></value[x]>

  </profile>
 </content>
</DocumentReference>

JSON Template 

{doco
  "resourceType" : "DocumentReference",
  // from Resource: id, meta, implicitRules, and language
  // from DomainResource: text, contained, extension, and modifierExtension
  "
  "

  "identifier" : [{ Identifier }], // Business identifiers for the document
  "version" : "<string>", // An explicitly assigned identifier of a variation of the content in the DocumentReference

  "basedOn" : [{ Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   |
   
  "
  "

   EnrollmentRequest|MedicationRequest|NutritionOrder|RequestOrchestration|
   ServiceRequest|VisionPrescription) }], // Procedure that caused this media to be created
  "status" : "<code>", // R!  current | superseded | entered-in-error
  "docStatus" : "<code>", // registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  "modality" : [{ CodeableConcept }], // Imaging modality used icon
  "type" : { CodeableConcept }, // Kind of document (LOINC if possible)
  "category" : [{ CodeableConcept }], // Categorization of document
  "subject" : { Reference(Any) }, // Who/what is the subject of the document
  "
  "
  "

  "context" : [{ Reference(Appointment|Encounter|EpisodeOfCare) }], // I Encounter the document reference is part of
  "event" : [{ CodeableReference(Any) }], // Main clinical acts documented icon
  "related" : [{ Reference(Any) }], // Related identifiers or resources associated with the document reference
  "bodyStructure" : [{ CodeableReference(BodyStructure) }], // Body structure included

  "facilityType" : { CodeableConcept }, // I Kind of facility where patient was seen
  "practiceSetting" : { CodeableConcept }, // I Additional details about where the content was created (e.g. clinical specialty)
  "period" : { Period }, // Time of service that is being documented
  "
  "|
   

  "date" : "<dateTime>", // When this document reference was created
  "author" : [{ Reference(CareTeam|Device|Group|Organization|Patient|
   Practitioner|PractitionerRole|RelatedPerson) }], // Who and/or what authored the document
  "attester" : [{ // Attests to accuracy of the document
    "mode" : { CodeableConcept }, // R!  personal | professional | legal | official
    "time" : "<dateTime>", // When the document was attested
    "|
    

    "party" : { Reference(Group|Organization|Patient|Practitioner|
    PractitionerRole|RelatedPerson) } // Who attested the document
  }],
  "custodian" : { Reference(Organization) }, // Organization which maintains the document
  "relatesTo" : [{ // Relationships to other documents
    "code" : { CodeableConcept }, // R!  The relationship type with another document
    "target" : { Reference(DocumentReference) } // R!  Target of the relationship
  }],
  "description" : "<markdown>", // Human-readable description
  "

  "securityLabel" : [{ CodeableConcept }], // Document security-tags

  "content" : [{ // R!  Document referenced
    "attachment" : { Attachment }, // R!  Where to access the document
    "profile" : [{ // Content profile rules for the document
      // value[x]: Code|uri|canonical. One of these 3:
      "valueCoding" : { Coding },
      "valueUri" : "<uri>",
      "valueCanonical" : "<canonical>"
    }]
  }]
}

Turtle Template 

@prefix fhir: <http://hl7.org/fhir/> .doco


[ a fhir:DocumentReference;
  fhir:nodeRole fhir:treeRoot; # if this is the parser root

  # from 
  # from 
  fhir:
  fhir:

  # from Resource: fhir:id, fhir:meta, fhir:implicitRules, and fhir:language
  # from DomainResource: fhir:text, fhir:contained, fhir:extension, and fhir:modifierExtension
  fhir:identifier  ( [ Identifier ] ... ) ; # 0..* Business identifiers for the document
  fhir:version [ string ] ; # 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference

  fhir:basedOn  ( [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract|
  |
  |
  
  fhir:
  fhir:

  CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest|MedicationRequest|
  NutritionOrder|RequestOrchestration|ServiceRequest|VisionPrescription) ] ... ) ; # 0..* Procedure that caused this media to be created
  fhir:status [ code ] ; # 1..1 current | superseded | entered-in-error
  fhir:docStatus [ code ] ; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  fhir:modality  ( [ CodeableConcept ] ... ) ; # 0..* Imaging modality used
  fhir:type [ CodeableConcept ] ; # 0..1 Kind of document (LOINC if possible)
  fhir:category  ( [ CodeableConcept ] ... ) ; # 0..* Categorization of document
  fhir:subject [ Reference(Any) ] ; # 0..1 Who/what is the subject of the document
  fhir:
  fhir:
  fhir:

  fhir:context  ( [ Reference(Appointment|Encounter|EpisodeOfCare) ] ... ) ; # 0..* I Encounter the document reference is part of
  fhir:event  ( [ CodeableReference(Any) ] ... ) ; # 0..* Main clinical acts documented
  fhir:related  ( [ Reference(Any) ] ... ) ; # 0..* Related identifiers or resources associated with the document reference
  fhir:bodyStructure  ( [ CodeableReference(BodyStructure) ] ... ) ; # 0..* Body structure included

  fhir:facilityType [ CodeableConcept ] ; # 0..1 I Kind of facility where patient was seen
  fhir:practiceSetting [ CodeableConcept ] ; # 0..1 I Additional details about where the content was created (e.g. clinical specialty)
  fhir:period [ Period ] ; # 0..1 Time of service that is being documented
  fhir:
  fhir:

  fhir:date [ dateTime ] ; # 0..1 When this document reference was created
  fhir:author  ( [ Reference(CareTeam|Device|Group|Organization|Patient|Practitioner|PractitionerRole|
  RelatedPerson) ] ... ) ; # 0..* Who and/or what authored the document
  fhir:attester ( [ # 0..* Attests to accuracy of the document
    fhir:mode [ CodeableConcept ] ; # 1..1 personal | professional | legal | official
    fhir:time [ dateTime ] ; # 0..1 When the document was attested
    fhir:

    fhir:party [ Reference(Group|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who attested the document

  ] ... ) ;
  fhir:custodian [ Reference(Organization) ] ; # 0..1 Organization which maintains the document
  fhir:relatesTo ( [ # 0..* Relationships to other documents
    fhir:code [ CodeableConcept ] ; # 1..1 The relationship type with another document
    fhir:target [ Reference(DocumentReference) ] ; # 1..1 Target of the relationship
  ] ... ) ;
  fhir:description [ markdown ] ; # 0..1 Human-readable description
  fhir:securityLabel  ( [ CodeableConcept ] ... ) ; # 0..* Document security-tags
  fhir:content ( [ # 1..* Document referenced
    fhir:attachment [ Attachment ] ; # 1..1 Where to access the document
    fhir:profile ( [ # 0..* Content profile rules for the document
      # value[x] : 1..1 Code|uri|canonical. One of these 3
        fhir:value [  a fhir:Coding ; Coding ]
        fhir: ]
        fhir: ]

        fhir:value [  a fhir:Uri ; uri ]
        fhir:value [  a fhir:Canonical ; canonical ]

    ] ... ) ;
  ] ... ) ;
]

Changes from both R4 and R4B

DocumentReference
DocumentReference.version
  • Added Element
DocumentReference.basedOn
  • Added Element
DocumentReference.docStatus
  • Remove code preliminary
  • Add codes registered , partial , corrected , appended , cancelled , deprecated , unknown
  • Now marked as Modifier
DocumentReference.modality
  • Added Element
DocumentReference.subject
  • Type Reference: Added Target Type Resource
  • Type Reference: Removed Target Types Patient, Practitioner, Group, Device
DocumentReference.context
  • Max Cardinality changed from 1 to *
  • Type changed from BackboneElement to Reference(Appointment | Encounter | EpisodeOfCare)
DocumentReference.event
  • Added Element
DocumentReference.bodySite DocumentReference.related
  • Added Element
DocumentReference.bodyStructure
  • Added Element
DocumentReference.facilityType
  • Added Element
DocumentReference.practiceSetting
  • Added Element
DocumentReference.period
  • Added Element
DocumentReference.date
  • Type changed from instant to dateTime
DocumentReference.author
  • Type Reference: Added Target Type CareTeam Types CareTeam, Group
DocumentReference.attester
  • Added Element
DocumentReference.attester.mode
  • Added Mandatory Element
DocumentReference.attester.time
  • Added Element
DocumentReference.attester.party
  • Added Element
DocumentReference.relatesTo.code
  • Type changed from code to CodeableConcept
  • Change binding strength from required to extensible
DocumentReference.description
  • Type changed from string to markdown
DocumentReference.securityLabel
  • Remove Binding `http://hl7.org/fhir/ValueSet/security-labels` (extensible)
DocumentReference.content.profile
  • Added Element
DocumentReference.content.profile.value[x]
  • Added Mandatory Element
DocumentReference.masterIdentifier
  • Deleted (-> identifier)
DocumentReference.authenticator
  • Deleted (-> attester)
DocumentReference.content.format
  • Deleted (-> content.profile)
DocumentReference.context.encounter
  • Deleted (-> context)
DocumentReference.context.event
  • Deleted (-> event)
DocumentReference.context.period
  • Deleted (-> period)
DocumentReference.context.facilityType
  • Deleted (-> facilityType)
DocumentReference.context.practiceSetting
  • Deleted (-> practiceSetting)
DocumentReference.context.sourcePatientInfo
  • Deleted (-> use extension http://hl7.org/fhir/StructureDefinition/documentreference-sourcepatient)
DocumentReference.context.related
  • Deleted (-> basedOn)

See the Full Difference for further information

This analysis is available for R4 as XML or JSON and for R4B as XML or JSON .

See R4 <--> R5 Conversion Maps (status = See Conversions Summary .)

 

Additional definitions: Master Definition XML + JSON , XML Schema / Schematron + JSON Schema , ShEx (for Turtle ) + see the extensions , the spreadsheet version & the dependency analysis

10.2.4.1 Terminology Bindings

Path ValueSet Type Documentation
DocumentReference.status DocumentReferenceStatus Required

The status of the document reference.

DocumentReference.docStatus CompositionStatus Required

The workflow/clinical status of the composition.

DocumentReference.modality Modality icon Extensible

Transitive closure of CID 33 Modality

DocumentReference.type FHIRDocumentTypeCodes Preferred

FHIR Document Codes - all LOINC codes where scale type = 'DOC'.

DocumentReference.category ReferencedItemCategoryValueSet Example

This is the code specifying the high-level kind of document (e.g. Prescription, Discharge Summary, Report, etc.). Made up of a set of non-healthcare specific codes and all LOINC codes where scale type = 'DOC'.

DocumentReference.event ActCode icon Example

A code specifying the particular kind of Act that the Act-instance represents within its class. Constraints: The kind of Act (e.g. physical examination, serum potassium, inpatient encounter, charge financial transaction, etc.) is specified with a code from one of several, typically external, coding systems. The coding system will depend on the class of Act, such as LOINC for observations, etc. Conceptually, the Act.code must be a specialization of the Act.classCode. This is why the structure of ActClass domain should be reflected in the superstructure of the ActCode domain and then individual codes or externally referenced vocabularies subordinated under these domains that reflect the ActClass structure. Act.classCode and Act.code are not modifiers of each other but the Act.code concept should really imply the Act.classCode concept. For a negative example, it is not appropriate to use an Act.code "potassium" together with and Act.classCode for "laboratory observation" to somehow mean "potassium laboratory observation" and then use the same Act.code for "potassium" together with Act.classCode for "medication" to mean "substitution of potassium". This mutually modifying use of Act.code and Act.classCode is not permitted.

DocumentReference.bodySite DocumentReference.bodyStructure SNOMEDCTBodyStructures Example

This value set includes all codes from SNOMED CT icon where concept is-a 442083009 (Anatomical or acquired body site (body structure)).

DocumentReference.facilityType FacilityTypeCodeValueSet Example

This is the code representing the type of organizational setting where the clinical encounter, service, interaction, or treatment occurred. The value set used for Healthcare Facility Type has been defined by HITSP to be the value set reproduced from HITSP C80 Table 2-147.

DocumentReference.practiceSetting PracticeSettingCodeValueSet Example

This is the code representing the clinical specialty of the clinician or provider who interacted with, treated, or provided a service to/for the patient. The value set used for clinical specialty has been limited by HITSP to the value set reproduced from HITSP C80 Table 2-149 Clinical Specialty Value Set Definition.

DocumentReference.attester.mode CompositionAttestationMode Preferred

The way in which a person authenticated a composition.

DocumentReference.relatesTo.code DocumentRelationshipType Extensible

The type of relationship between documents.

DocumentReference.securityLabel SecurityLabelExamples Example

A sample of security labels from Healthcare Privacy and Security Classification System as the combination of data and event codes.

DocumentReference.content.profile.value[x] HL7FormatCodes icon Preferred

The HL7-FormatCodes value set is defined to be the set of FormatCode(s) defined by implementation guides published by HL7 and other SDOs. The use of a formatCode from the FormatCodes value set specifies the technical format that a document conforms to. The formatCode is a further specialization more detailed than the mime-type. The formatCode provides sufficient information to allow any potential document content consumer to know if it can process and/or display the content of the document based on the document encoding, structure and template conformance indicated by the formatCode. The set of formatCodes is intended to be extensible. The Content Logical Description is defined intentionally to permit formatCodes defined by other Standards Development Organizations to be added by inclusion of additional formatCode Code Systems.

10.2.4.2 Constraints

UniqueKey Level Location Description Expression
img  docRef-1 Warning (base) facilityType SHALL only be present if context is not an encounter facilityType.empty() or context.where(resolve() is Encounter).empty()
img  docRef-2 Warning (base) practiceSetting SHALL only be present if context is not present practiceSetting.empty() or context.where(resolve() is Encounter).empty()

10.2.5 Implementation Notes

  • 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
  • The _content search parameter shall search across the DocumentReference.content.attachment.data, DocumentReference.content.attachment.data , and DocumentReference.content.url. DocumentReference.content.attachment.url .
  • If the referenced resource changes, then the corresponding DocumentRefererence DocumentReference may be out of sync temporarily. Coordination will be needed to ensure that the DocumentReference gets updated if the referenced resource changes (and to not allow updates to the DocumentReference that cause it to be misaligned with the referenced resource).
  • DocumentReference might be appropriate for including a rendered DICOM image in cases where the full image context is not important. When this is done, the DocumentReference.event.reference should point at the ImagingStudy or ImagingSelection .

10.2.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource , and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
attester reference Who attested the document DocumentReference.attester.party
( Practitioner , Group , Organization , Patient , PractitionerRole , RelatedPerson )
author reference Who and/or what authored the document DocumentReference.author
( Practitioner , Group , Organization , CareTeam , Device , Patient , PractitionerRole , RelatedPerson )
based-on reference Procedure that caused this media to be created DocumentReference.basedOn
( Appointment , MedicationRequest , RequestOrchestration , VisionPrescription , ServiceRequest , SupplyRequest , AppointmentResponse , CoverageEligibilityRequest , CarePlan , EnrollmentRequest , NutritionOrder , DeviceRequest , Contract , Claim , CommunicationRequest , ImmunizationRecommendation )
bodysite body-structure token The body site structure studied DocumentReference.bodySite.concept DocumentReference.bodyStructure.concept
bodysite-reference body-structure-reference reference The body site structure studied DocumentReference.bodySite.reference DocumentReference.bodyStructure.reference
category token Categorization of document DocumentReference.category
contenttype token Mime type of the content, with charset etc. DocumentReference.content.attachment.contentType
context reference Context of the document content DocumentReference.context
( Appointment , EpisodeOfCare , Encounter )
creation date Date attachment was first created DocumentReference.content.attachment.creation
custodian reference Organization which maintains the document DocumentReference.custodian
( Organization )
date date When this document reference was created DocumentReference.date 27 22 Resources
description string Human-readable description DocumentReference.description
doc-status token preliminary | final | amended | entered-in-error DocumentReference.docStatus
event-code token Main clinical acts documented DocumentReference.event.concept
event-reference reference Main clinical acts documented DocumentReference.event.reference
facility token Kind of facility where patient was seen DocumentReference.facilityType
format-canonical reference uri Profile canonical content rules for the document (DocumentReference.content.profile.value.ofType(canonical))
format-code token Format code content rules for the document (DocumentReference.content.profile.value.ofType(Coding))
format-uri uri Profile URI content rules for the document (DocumentReference.content.profile.value.ofType(uri))
identifier token Identifier of the attachment binary DocumentReference.identifier 65 58 Resources
language token Human language of the content (BCP-47) DocumentReference.content.attachment.language
location uri Uri where the data can be found DocumentReference.content.attachment.url
modality token The modality used DocumentReference.modality
patient reference Who/what is the subject of the document DocumentReference.subject.where(resolve() is Patient)
( Patient ) 		66 60 Resources
period date Time of service that is being documented DocumentReference.period
related reference Related identifiers or resources DocumentReference.related
(Any)
relatesto reference Target of the relationship DocumentReference.relatesTo.target
( DocumentReference )
relation token replaces | transforms | signs | appends DocumentReference.relatesTo.code
relationship composite Combination of relation and relatesTo On DocumentReference.relatesTo:
  relatesto: code target
  relation: target code
security-label token Document security-tags DocumentReference.securityLabel
setting token Additional details about where the content was created (e.g. clinical specialty) DocumentReference.practiceSetting
status token current | superseded | entered-in-error DocumentReference.status
subject reference Who/what is the subject of the document DocumentReference.subject
(Any)
type token Kind of document (LOINC if possible) DocumentReference.type 11 10 Resources
version string The business version identifier DocumentReference.version