Release 4B 5 Ballot

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0-ballot: R5 Ballot - STU see ballot notes ). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.42 10.2 Resource DocumentReference - Content

Structured Documents Orders and Observations icon Work Group Maturity Level : 3   Trial Use Security Category : Not Classified Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

A reference to a document of any kind for any purpose. Provides metadata about the document so that While the document can be discovered and managed. The scope of term “document” implies a document is more narrow focus, for this resource this "document" encompasses any seralized serialized object with a mime-type, so it includes formal patient centric patient-centric documents (CDA), cliical clinical notes, scanned paper, and non-patient specific documents like policy text. 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.

2.42.1 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 displayed 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 , such and as profiled in IHE Mobile access Access to Health Documents icon .

DocumentReference is metadata describing a document 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

2.42.2 10.2.2 Boundaries and Relationships

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. This resource DocumentReference is mainly 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, or a DICOM 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 .

2.42.3 10.2.3 References to this Resource

This resource is referenced by

2.42.4 10.2.4 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
. . DocumentReference TU 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
. . . masterIdentifier identifier Σ 0..1 0..* Identifier Master Version Specific Identifier Business identifiers for the document

. . identifier . basedOn Σ 0..* Identifier Reference ( Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | EpisodeOfCare | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription ) Other identifiers for the document Procedure that caused this media to be created

. . . status ?! Σ 1..1 code current | superseded | entered-in-error
DocumentReferenceStatus ( Required )
. . . type Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
FHIR Document Type Codes ( Preferred )
. . . category Σ 0..* CodeableConcept Categorization of document
Document Class Referenced Item Category Value Set ( Example )

. . . subject Σ 0..1 Reference ( Patient | Practitioner | Group | Device Any ) Who/what is the subject of the document
. . date . context 0..* Reference ( Appointment | Encounter | EpisodeOfCare ) Context of the document content

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

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

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

. . . . mode 1..1 CodeableConcept personal | professional | legal | official
CompositionAttestationMode ( Preferred )
.... time 0..1 dateTime When the document was attested
... . authenticator party 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization ) Who/what authenticated 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 code CodeableConcept replaces | transforms | signs | appends The relationship type with another document
DocumentRelationshipType ( Required Extensible )
. . . . target Σ 1..1 Reference ( DocumentReference ) Target of the relationship
. . . description Σ 0..1 string markdown Human-readable description
. . . securityLabel Σ 0..* CodeableConcept Document security-tags
SecurityLabels Example set of Security Labels ( Extensible Example )

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

. . . . attachment Σ 1..1 Attachment Where to access the document
. . . format . profile Σ 0..1 0..* Coding BackboneElement Format/content Content profile rules for the document
DocumentReference Format Code Set ( Preferred )
. . . . context . value[x] Σ 0..1 1..1 BackboneElement Clinical context of document encounter 0..* Code|uri|canonical
HL7 ValueSet of Format Codes for use with Document Sharing icon Reference ( Encounter | EpisodeOfCare Preferred ) Context of the document content
. . event 0..* CodeableConcept Main clinical acts documented v3 Code System ActCode ( Example ) . . . . period valueCoding Σ 0..1 Period Coding Time of service that is being documented
. . . facilityType . . . valueUri 0..1 CodeableConcept uri Kind of facility where patient was seen Facility Type Code Value Set ( Example )
. . practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) Practice Setting Code Value Set ( Example ) . sourcePatientInfo 0..1 Reference ( Patient ) Patient demographics from source . . . related valueCanonical 0..* Reference ( Any canonical ) () Related identifiers or resources

doco Documentation for this format

See the Extensions for this resource

UML Diagram ( Legend )

DocumentReference ( DomainResource ) Document identifier as assigned by the source of the document. This identifier is specific to this version of Other business identifiers associated with the document. This unique identifier may be used elsewhere to identify this document, including version of the document independent identifiers masterIdentifier identifier : Identifier [0..1] [0..*] 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 identifier basedOn : Identifier Reference [0..*] « Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | EpisodeOfCare | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription » The status of this document reference (this element modifies the meaning of other elements) status : code [1..1] « null (Strength=Required) DocumentReferenceStatus ! » The status of the underlying document docStatus : code [0..1] « null (Strength=Required) CompositionStatus ! » 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) DocumentClassValueSet 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] « Patient Any | Practitioner » Describes the clinical encounter or type of care that the document content is associated with context : Reference [0..*] « Appointment | Group Encounter | Device EpisodeOfCare » 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..*] « ; null (Strength=Example) ActCode ?? » The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) FacilityTypeCodeValueSet ?? » 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 ?? » 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 [0..1] Identifies who is responsible for adding the information to the document author : Reference [0..*] « Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson » Which person or organization authenticates that this document is valid authenticator : Reference [0..1] « Practitioner | PractitionerRole | Organization CareTeam » 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 : string markdown [0..1] A set of Security-Tag codes specifying the level of privacy/security of the Document. Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, data elements in DocumentReference, while DocumentReference.securityLabel contains a snapshot of the security labels on for the document the reference refers to 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=Extensible) (Strength=Example) All Security Labels 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 » RelatesTo The type of relationship that this document has with anther document code : code CodeableConcept [1..1] « null (Strength=Required) (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] An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType format : Coding [0..1] « null (Strength=Preferred) DocumentReferenceFormatCodeSet ? » Context Profile Describes the clinical encounter or type of care that the document content is associated with Code|uri|canonical encounter value[x] : Reference DataType [0..*] [1..1] « Encounter Coding | EpisodeOfCare » 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 : CodeableConcept [0..*] « null (Strength=Example) ActCode ?? » The time period over which the service that is described by the document was provided period uri : Period | canonical [0..1] ; The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) (Strength=Preferred) FacilityTypeCodeValueSet HL7FormatCodes ?? ? » 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 ?? » The Patient Information as known when A participant who has authenticated the accuracy of the document was published. May be a reference to a version specific, or contained sourcePatientInfo : Reference [0..1] « Patient attester » Related identifiers or resources associated with the DocumentReference related : Reference [0..*] « Any » Relationships that this document has with other document references that already exist relatesTo [0..*] The An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format referenced. There may be multiple content element repetitions, each with a different format indicated in the mimeType content profile [1..*] [0..*] The clinical context in which document and format referenced. If there are multiple content element repetitions, these must all represent the same document was prepared in different format, or attachment metadata context content [0..1] [1..*]

XML Template 

<

<DocumentReference xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</masterIdentifier>
 <</identifier>

 <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier>
 <basedOn><!-- 0..* Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   EnrollmentRequest|EpisodeOfCare|ImmunizationRecommendation|MedicationRequest|
   NutritionOrder|RequestOrchestration|ServiceRequest|SupplyRequest|
   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 -->

 <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <</category>
 <</subject>

 <category><!-- 0..* CodeableConcept Categorization of document --></category>
 <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject>
 <context><!-- 0..* Reference(Appointment|Encounter|EpisodeOfCare) Context of the document content --></context>
 <event><!-- 0..* CodeableReference Main clinical acts documented icon --></event>
 <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
 <practiceSetting><!-- 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>

 <date value="[instant]"/><!-- 0..1 When this document reference was created -->
 <|

 <author><!-- 0..* Reference(CareTeam|Device|Organization|Patient|Practitioner|

   PractitionerRole|RelatedPerson) Who and/or what authored the document --></author>
 <</authenticator>

 <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><!-- 0..1 Reference(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>
 <
 <</securityLabel>
 <

 <description value="[markdown]"/><!-- 0..1 Human-readable description -->
 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>
 <content>  <!-- 1..* Document referenced -->

  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <</format>

  <profile>  <!-- 0..* Content profile rules for the document -->
   <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical icon --></value[x]>
  </profile>

 </content>
 <
  <</encounter>
  <</event>
  <</period>
  <</facilityType>
  <</practiceSetting>
  <</sourcePatientInfo>
  <</related>
 </context>

</DocumentReference>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "DocumentReference",

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

  "identifier" : [{ Identifier }], // Business identifiers for the document
  "basedOn" : [{ Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   EnrollmentRequest|EpisodeOfCare|ImmunizationRecommendation|MedicationRequest|
   NutritionOrder|RequestOrchestration|ServiceRequest|SupplyRequest|
   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

  "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) }], // Context of the document content
  "event" : [{ CodeableReference }], // Main clinical acts documented icon
  "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
  "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
  "period" : { Period }, // Time of service that is being documented

  "date" : "<instant>", // When this document reference was created
  "|

  "author" : [{ Reference(CareTeam|Device|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(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:;

[ a fhir:DocumentReference;

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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:

  fhir:DocumentReference.identifier [ Identifier ], ... ; # 0..* Business identifiers for the document
  fhir:DocumentReference.basedOn [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract|
  CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest|EpisodeOfCare|
  ImmunizationRecommendation|MedicationRequest|NutritionOrder|
  RequestOrchestration|ServiceRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Procedure that caused this media to be created
  fhir:DocumentReference.status [ code ]; # 1..1 current | superseded | entered-in-error
  fhir:

  fhir:DocumentReference.docStatus [ code ]; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  fhir:DocumentReference.type [ CodeableConcept ]; # 0..1 Kind of document (LOINC if possible)
  fhir:DocumentReference.category [ CodeableConcept ], ... ; # 0..* Categorization of document
  fhir:

  fhir:DocumentReference.subject [ Reference(Any) ]; # 0..1 Who/what is the subject of the document
  fhir:DocumentReference.context [ Reference(Appointment|Encounter|EpisodeOfCare) ], ... ; # 0..* Context of the document content
  fhir:DocumentReference.event [ CodeableReference ], ... ; # 0..* Main clinical acts documented
  fhir:DocumentReference.facilityType [ CodeableConcept ]; # 0..1 Kind of facility where patient was seen
  fhir:DocumentReference.practiceSetting [ CodeableConcept ]; # 0..1 Additional details about where the content was created (e.g. clinical specialty)
  fhir:DocumentReference.period [ Period ]; # 0..1 Time of service that is being documented

  fhir:DocumentReference.date [ instant ]; # 0..1 When this document reference was created
  fhir:
  fhir:

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

  fhir:DocumentReference.custodian [ Reference(Organization) ]; # 0..1 Organization which maintains the document
  fhir:DocumentReference.relatesTo [ # 0..* Relationships to other documents
    fhir:

    fhir:DocumentReference.relatesTo.code [ CodeableConcept ]; # 1..1 The relationship type with another document

    fhir:DocumentReference.relatesTo.target [ Reference(DocumentReference) ]; # 1..1 Target of the relationship
  ], ...;
  fhir:
  fhir:
  fhir:

  fhir:DocumentReference.description [ markdown ]; # 0..1 Human-readable description
  fhir:DocumentReference.securityLabel [ CodeableConcept ], ... ; # 0..* Document security-tags
  fhir:DocumentReference.content [ # 1..* Document referenced

    fhir:DocumentReference.content.attachment [ Attachment ]; # 1..1 Where to access the document
    fhir:

    fhir:DocumentReference.content.profile [ # 0..* Content profile rules for the document
      # DocumentReference.content.profile.value[x] : 1..1 Code|uri|canonical. One of these 3
        fhir:DocumentReference.content.profile.valueCoding [ Coding ]
        fhir:DocumentReference.content.profile.valueUri [ uri ]
        fhir:DocumentReference.content.profile.valueCanonical [ canonical ]
    ], ...;

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ];

]

Changes since R4

DocumentReference
DocumentReference.basedOn
  • No Changes Added Element
DocumentReference.subject
  • Type Reference: Added Target Type Resource
  • Type Reference: Removed Target Types Patient, Practitioner, Group, Device
  • 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)
  • Type changed from BackboneElement to Reference(Appointment | Encounter | EpisodeOfCare)
DocumentReference.event
  • Added Element
DocumentReference.facilityType
  • Added Element
DocumentReference.practiceSetting
  • Added Element
DocumentReference.period
  • Added Element
DocumentReference.author
  • Type Reference: Added Target Type CareTeam
  • Type Reference: Added Target Type CareTeam
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
  • Change binding strength from required to extensible
DocumentReference.description
  • Type changed from string to markdown
  • Type changed from string to markdown
DocumentReference.securityLabel
  • Remove Binding http://hl7.org/fhir/ValueSet/security-labels (extensible)
  • 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
DocumentReference.authenticator
  • deleted
DocumentReference.content.format
  • deleted
DocumentReference.context.encounter
  • deleted
DocumentReference.context.event
  • deleted
DocumentReference.context.period
  • deleted
DocumentReference.context.facilityType
  • deleted
DocumentReference.context.practiceSetting
  • deleted
DocumentReference.context.sourcePatientInfo
  • deleted
DocumentReference.context.related
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Conversions between R3 and R4 See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute .)

Structure

Name Flags Card. Type Description & Constraints doco
. . DocumentReference TU 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
. . . masterIdentifier identifier Σ 0..1 0..* Identifier Master Version Specific Identifier Business identifiers for the document

. . identifier . basedOn Σ 0..* Identifier Reference ( Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | EpisodeOfCare | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription ) Other identifiers for the document Procedure that caused this media to be created

. . . status ?! Σ 1..1 code current | superseded | entered-in-error
DocumentReferenceStatus ( Required )
. . . type Σ 0..1 CodeableConcept Kind of document (LOINC if possible)
FHIR Document Type Codes ( Preferred )
. . . category Σ 0..* CodeableConcept Categorization of document
Document Class Referenced Item Category Value Set ( Example )

. . . subject Σ 0..1 Reference ( Patient | Practitioner | Group | Device Any ) Who/what is the subject of the document
. . date . context 0..* Reference ( Appointment | Encounter | EpisodeOfCare ) Context of the document content

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

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

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

.... mode 1..1 CodeableConcept personal | professional | legal | official
CompositionAttestationMode ( Preferred )
. . . . time 0..1 dateTime When the document was attested
... . authenticator party 0..1 Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization ) Who/what authenticated 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 code CodeableConcept replaces | transforms | signs | appends The relationship type with another document
DocumentRelationshipType ( Required Extensible )
. . . . target Σ 1..1 Reference ( DocumentReference ) Target of the relationship
. . . description Σ 0..1 string markdown Human-readable description
. . . securityLabel Σ 0..* CodeableConcept Document security-tags
SecurityLabels Example set of Security Labels ( Extensible Example )

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

. . . . attachment Σ 1..1 Attachment Where to access the document
. . . format . profile Σ 0..1 0..* Coding BackboneElement Format/content Content profile rules for the document
DocumentReference Format Code Set ( Preferred )
. . . . context . value[x] Σ 0..1 1..1 BackboneElement Clinical context of document encounter 0..* Code|uri|canonical
HL7 ValueSet of Format Codes for use with Document Sharing icon Reference ( Encounter | EpisodeOfCare Preferred ) Context of the document content
. . event 0..* CodeableConcept Main clinical acts documented v3 Code System ActCode ( Example ) . . . . period valueCoding Σ 0..1 Period Coding Time of service that is being documented
. . . facilityType . . . valueUri 0..1 CodeableConcept uri Kind of facility where patient was seen Facility Type Code Value Set ( Example )
. . practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) Practice Setting Code Value Set ( Example ) . sourcePatientInfo 0..1 Reference ( Patient ) Patient demographics from source . . . related valueCanonical 0..* Reference ( Any canonical ) () Related identifiers or resources

doco Documentation for this format

See the Extensions for this resource

UML Diagram ( Legend )

DocumentReference ( DomainResource ) Document identifier as assigned by the source of the document. This identifier is specific to this version of Other business identifiers associated with the document. This unique identifier may be used elsewhere to identify this document, including version of the document independent identifiers masterIdentifier identifier : Identifier [0..1] [0..*] 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 identifier basedOn : Identifier Reference [0..*] « Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | EpisodeOfCare | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription » The status of this document reference (this element modifies the meaning of other elements) status : code [1..1] « null (Strength=Required) DocumentReferenceStatus ! » The status of the underlying document docStatus : code [0..1] « null (Strength=Required) CompositionStatus ! » 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) DocumentClassValueSet 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] « Patient Any | Practitioner » Describes the clinical encounter or type of care that the document content is associated with context : Reference [0..*] « Appointment | Group Encounter | Device EpisodeOfCare » 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..*] « ; null (Strength=Example) ActCode ?? » The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) FacilityTypeCodeValueSet ?? » 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 ?? » 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 [0..1] Identifies who is responsible for adding the information to the document author : Reference [0..*] « Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson » Which person or organization authenticates that this document is valid authenticator : Reference [0..1] « Practitioner | PractitionerRole | Organization CareTeam » 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 : string markdown [0..1] A set of Security-Tag codes specifying the level of privacy/security of the Document. Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, data elements in DocumentReference, while DocumentReference.securityLabel contains a snapshot of the security labels on for the document the reference refers to 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=Extensible) (Strength=Example) All Security Labels 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 » RelatesTo The type of relationship that this document has with anther document code : code CodeableConcept [1..1] « null (Strength=Required) (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] An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType format : Coding [0..1] « null (Strength=Preferred) DocumentReferenceFormatCodeSet ? » Context Profile Describes the clinical encounter or type of care that the document content is associated with Code|uri|canonical encounter value[x] : Reference DataType [0..*] [1..1] « Encounter Coding | EpisodeOfCare » 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 : CodeableConcept [0..*] « null (Strength=Example) ActCode ?? » The time period over which the service that is described by the document was provided period uri : Period | canonical [0..1] ; The kind of facility where the patient was seen facilityType : CodeableConcept [0..1] « null (Strength=Example) (Strength=Preferred) FacilityTypeCodeValueSet HL7FormatCodes ?? ? » 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 ?? » The Patient Information as known when A participant who has authenticated the accuracy of the document was published. May be a reference to a version specific, or contained sourcePatientInfo : Reference [0..1] « Patient attester » Related identifiers or resources associated with the DocumentReference related : Reference [0..*] « Any » Relationships that this document has with other document references that already exist relatesTo [0..*] The An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format referenced. There may be multiple content element repetitions, each with a different format indicated in the mimeType content profile [1..*] [0..*] The clinical context in which document and format referenced. If there are multiple content element repetitions, these must all represent the same document was prepared in different format, or attachment metadata context content [0..1] [1..*]

XML Template 

<

<DocumentReference xmlns="http://hl7.org/fhir"> doco

 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <</masterIdentifier>
 <</identifier>

 <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier>
 <basedOn><!-- 0..* Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   EnrollmentRequest|EpisodeOfCare|ImmunizationRecommendation|MedicationRequest|
   NutritionOrder|RequestOrchestration|ServiceRequest|SupplyRequest|
   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 -->

 <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type>
 <</category>
 <</subject>

 <category><!-- 0..* CodeableConcept Categorization of document --></category>
 <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject>
 <context><!-- 0..* Reference(Appointment|Encounter|EpisodeOfCare) Context of the document content --></context>
 <event><!-- 0..* CodeableReference Main clinical acts documented icon --></event>
 <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
 <practiceSetting><!-- 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>

 <date value="[instant]"/><!-- 0..1 When this document reference was created -->
 <|

 <author><!-- 0..* Reference(CareTeam|Device|Organization|Patient|Practitioner|

   PractitionerRole|RelatedPerson) Who and/or what authored the document --></author>
 <</authenticator>

 <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><!-- 0..1 Reference(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>
 <
 <</securityLabel>
 <

 <description value="[markdown]"/><!-- 0..1 Human-readable description -->
 <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel>
 <content>  <!-- 1..* Document referenced -->

  <attachment><!-- 1..1 Attachment Where to access the document --></attachment>
  <</format>

  <profile>  <!-- 0..* Content profile rules for the document -->
   <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical icon --></value[x]>
  </profile>

 </content>
 <
  <</encounter>
  <</event>
  <</period>
  <</facilityType>
  <</practiceSetting>
  <</sourcePatientInfo>
  <</related>
 </context>

</DocumentReference>

JSON Template 

{doco
  "resourceType" : "",

  "resourceType" : "DocumentReference",

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

  "identifier" : [{ Identifier }], // Business identifiers for the document
  "basedOn" : [{ Reference(Appointment|AppointmentResponse|CarePlan|Claim|
   CommunicationRequest|Contract|CoverageEligibilityRequest|DeviceRequest|
   EnrollmentRequest|EpisodeOfCare|ImmunizationRecommendation|MedicationRequest|
   NutritionOrder|RequestOrchestration|ServiceRequest|SupplyRequest|
   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

  "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) }], // Context of the document content
  "event" : [{ CodeableReference }], // Main clinical acts documented icon
  "facilityType" : { CodeableConcept }, // Kind of facility where patient was seen
  "practiceSetting" : { CodeableConcept }, // Additional details about where the content was created (e.g. clinical specialty)
  "period" : { Period }, // Time of service that is being documented

  "date" : "<instant>", // When this document reference was created
  "|

  "author" : [{ Reference(CareTeam|Device|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(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:;

[ a fhir:DocumentReference;

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

  # from Resource: .id, .meta, .implicitRules, and .language
  # from DomainResource: .text, .contained, .extension, and .modifierExtension
  fhir:
  fhir:

  fhir:DocumentReference.identifier [ Identifier ], ... ; # 0..* Business identifiers for the document
  fhir:DocumentReference.basedOn [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract|
  CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest|EpisodeOfCare|
  ImmunizationRecommendation|MedicationRequest|NutritionOrder|
  RequestOrchestration|ServiceRequest|SupplyRequest|VisionPrescription) ], ... ; # 0..* Procedure that caused this media to be created
  fhir:DocumentReference.status [ code ]; # 1..1 current | superseded | entered-in-error
  fhir:

  fhir:DocumentReference.docStatus [ code ]; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown

  fhir:DocumentReference.type [ CodeableConcept ]; # 0..1 Kind of document (LOINC if possible)
  fhir:DocumentReference.category [ CodeableConcept ], ... ; # 0..* Categorization of document
  fhir:

  fhir:DocumentReference.subject [ Reference(Any) ]; # 0..1 Who/what is the subject of the document
  fhir:DocumentReference.context [ Reference(Appointment|Encounter|EpisodeOfCare) ], ... ; # 0..* Context of the document content
  fhir:DocumentReference.event [ CodeableReference ], ... ; # 0..* Main clinical acts documented
  fhir:DocumentReference.facilityType [ CodeableConcept ]; # 0..1 Kind of facility where patient was seen
  fhir:DocumentReference.practiceSetting [ CodeableConcept ]; # 0..1 Additional details about where the content was created (e.g. clinical specialty)
  fhir:DocumentReference.period [ Period ]; # 0..1 Time of service that is being documented

  fhir:DocumentReference.date [ instant ]; # 0..1 When this document reference was created
  fhir:
  fhir:

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

  fhir:DocumentReference.custodian [ Reference(Organization) ]; # 0..1 Organization which maintains the document
  fhir:DocumentReference.relatesTo [ # 0..* Relationships to other documents
    fhir:

    fhir:DocumentReference.relatesTo.code [ CodeableConcept ]; # 1..1 The relationship type with another document

    fhir:DocumentReference.relatesTo.target [ Reference(DocumentReference) ]; # 1..1 Target of the relationship
  ], ...;
  fhir:
  fhir:
  fhir:

  fhir:DocumentReference.description [ markdown ]; # 0..1 Human-readable description
  fhir:DocumentReference.securityLabel [ CodeableConcept ], ... ; # 0..* Document security-tags
  fhir:DocumentReference.content [ # 1..* Document referenced

    fhir:DocumentReference.content.attachment [ Attachment ]; # 1..1 Where to access the document
    fhir:

    fhir:DocumentReference.content.profile [ # 0..* Content profile rules for the document
      # DocumentReference.content.profile.value[x] : 1..1 Code|uri|canonical. One of these 3
        fhir:DocumentReference.content.profile.valueCoding [ Coding ]
        fhir:DocumentReference.content.profile.valueUri [ uri ]
        fhir:DocumentReference.content.profile.valueCanonical [ canonical ]
    ], ...;

  ], ...;
  fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
    fhir:
  ];

]

Changes since Release 4

DocumentReference
DocumentReference.basedOn
  • No Changes Added Element
DocumentReference.subject
  • Type Reference: Added Target Type Resource
  • Type Reference: Removed Target Types Patient, Practitioner, Group, Device
  • 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)
  • Type changed from BackboneElement to Reference(Appointment | Encounter | EpisodeOfCare)
DocumentReference.event
  • Added Element
DocumentReference.facilityType
  • Added Element
DocumentReference.practiceSetting
  • Added Element
DocumentReference.period
  • Added Element
DocumentReference.author
  • Type Reference: Added Target Type CareTeam
  • Type Reference: Added Target Type CareTeam
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
  • Change binding strength from required to extensible
DocumentReference.description
  • Type changed from string to markdown
  • Type changed from string to markdown
DocumentReference.securityLabel
  • Remove Binding http://hl7.org/fhir/ValueSet/security-labels (extensible)
  • 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
DocumentReference.authenticator
  • deleted
DocumentReference.content.format
  • deleted
DocumentReference.context.encounter
  • deleted
DocumentReference.context.event
  • deleted
DocumentReference.context.period
  • deleted
DocumentReference.context.facilityType
  • deleted
DocumentReference.context.practiceSetting
  • deleted
DocumentReference.context.sourcePatientInfo
  • deleted
DocumentReference.context.related
  • deleted

See the Full Difference for further information

This analysis is available as XML or JSON .

Conversions between R3 and R4 See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute .)

 

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

2.42.4.1 10.2.4.1 Terminology Bindings

DocumentReference.relatesTo.code DocumentReference.securityLabel DocumentReference.content.format DocumentReference.context.event DocumentReference.context.facilityType DocumentReference.context.practiceSetting
Path Definition Type Reference
DocumentReference.status

The status of the document reference.

Required DocumentReferenceStatus
DocumentReference.docStatus

The workflow/clinical status of the composition.

Required CompositionStatus
DocumentReference.type

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

Preferred FHIRDocumentTypeCodes
DocumentReference.category

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'.

Example DocumentClassValueSet ReferencedItemCategoryValueSet
DocumentReference.event

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.

Required Example DocumentRelationshipType ActCode icon
DocumentReference.facilityType

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.

Extensible Example All Security Labels FacilityTypeCodeValueSet
DocumentReference.practiceSetting

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.

Example PracticeSettingCodeValueSet
DocumentReference.attester.mode

The way in which a person authenticated a composition.

Preferred DocumentReferenceFormatCodeSet CompositionAttestationMode
DocumentReference.relatesTo.code

The type of relationship between documents.

Example Extensible ActCode DocumentRelationshipType
DocumentReference.securityLabel

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

Example FacilityTypeCodeValueSet SecurityLabelExamples
DocumentReference.content.profile.value[x]

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.

Example Preferred PracticeSettingCodeValueSet HL7FormatCodes icon

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()

2.42.5 10.2.5 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
    • 2.42.5.1 Generating a Document Reference A client can ask a server to generate a document reference from a document.
  • The server reads _content search parameter shall search across the existing document DocumentReference.content.attachment.data, and generates a matching DocumentReference resource, or returns one it has previously generated. Servers DocumentReference.content.url.
  • If the referenced resource changes, then the corresponding DocumentRefererence may be able to return or generate document references for the following types out of content: Type Comments FHIR Documents The uri refers to an existing Document CDA Document The uri is a reference sync temporarily. Coordination will be needed to a Binary end-point that returns either a CDA document, or some kind of CDA Package ensure that the server knows how to process (e.g., an IHE .zip) Other The server can be asked to generate a document reference for other kinds of documents. For some of these documents (e.g., PDF documents) a server could only provide a document reference DocumentReference gets updated if it already existed or the server had special knowledge of the document. The server either returns a search result containing a single document reference, or it returns an error. If the URI refers referenced resource changes (and to another server, it is at the discretion of the server whether not allow updates 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 DocumentReference that cause it to one of the document types described above. Other parameters may be supplied: Name Meaning persist Whether to store the document at the document end-point (/Document) or not, once it is generated. Value = true or false (default is for misaligned with the server to decide). referenced resource).

2.42.6 10.2.6 Search Parameters

Search parameters for 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
authenticator attester reference Who/what authenticated Who attested the document DocumentReference.authenticator DocumentReference.attester.party
( Practitioner , Organization , Patient , PractitionerRole , RelatedPerson )
author reference Who and/or what authored the document DocumentReference.author
( Practitioner , 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 , EpisodeOfCare , NutritionOrder , DeviceRequest , Contract , Claim , CommunicationRequest , ImmunizationRecommendation )
category token Categorization of document DocumentReference.category
contenttype N 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 N date Date attachment was first created DocumentReference.content.attachment.creation
custodian reference Organization which maintains the document DocumentReference.custodian
( Organization )
date N date When this document reference was created DocumentReference.date
description N string Human-readable description DocumentReference.description
encounter doc-status N reference token Context of the document content preliminary | final | amended | entered-in-error DocumentReference.context.encounter.where(resolve() is Encounter) ( Encounter ) DocumentReference.docStatus
event event-code token Main clinical acts documented DocumentReference.context.event DocumentReference.event.concept
event-reference reference Main clinical acts documented DocumentReference.event.reference
facility token Kind of facility where patient was seen DocumentReference.context.facilityType DocumentReference.facilityType
format format-canonical reference Profile canonical content rules for the document (DocumentReference.content.profile.value as canonical)
format-code token Format/content Format code content rules for the document DocumentReference.content.format (DocumentReference.content.profile.value as Coding)
format-uri uri Profile URI content rules for the document (DocumentReference.content.profile.value as uri)
identifier token Master Version Specific Identifier of the attachment binary DocumentReference.masterIdentifier | DocumentReference.identifier
language N token Human language of the content (BCP-47) DocumentReference.content.attachment.language
location N uri Uri where the data can be found DocumentReference.content.attachment.url
patient reference Who/what is the subject of the document DocumentReference.subject.where(resolve() is Patient)
( Patient )
period date Time of service that is being documented DocumentReference.context.period related reference Related identifiers or resources DocumentReference.context.related (Any) DocumentReference.period
relatesto reference Target of the relationship DocumentReference.relatesTo.target
( DocumentReference )
relation N token replaces | transforms | signs | appends DocumentReference.relatesTo.code
relationship composite Combination of relation and relatesTo On DocumentReference.relatesTo:
  relatesto: code
  relation: target
security-label token Document security-tags DocumentReference.securityLabel
setting token Additional details about where the content was created (e.g. clinical specialty) DocumentReference.context.practiceSetting DocumentReference.practiceSetting
status N token current | superseded | entered-in-error DocumentReference.status
subject reference Who/what is the subject of the document DocumentReference.subject
( Practitioner , Group , Device , Patient ) (Any)
type token Kind of document (LOINC if possible) DocumentReference.type