1). 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 Final QA
R4B R4 R3 R2

This page is sometimes known as the "title" description : string 0..1 A code specifying the level of confidentiality of the XDS Document (this element modifies the meaning of other elements) confidentiality : CodeableConcept 0..* << Codes specifying the level of confidentiality of the composition DocumentConfidentiality >> The primary language in which the source document is written primaryLanguage : code 0..1 << A human language Language >> The mime type of the source document mimeType : code 1..1 << The mime type of an attachment MimeType >> An identifier that identifies that the format and content part of the document conforms to additional rules beyond the base format indicated in the mimeType format : uri FHIR Specification (v5.0.0-draft-final: Final QA Preview for R5 - see ballot notes 0..* ). The size of the source document this reference refers to in bytes size : integer 0..1 A hash of the source document to ensure that changes have not occurred hash : string 0..1 A url at current version which the document can be accessed location : uri 0..1 RelatesTo The type of relationship that this document has with anther document code : code 1..1 << The type of relationship between documents DocumentRelationshipType >> The target document of supercedes this relationship target : Resource ( DocumentReference ) 1..1 Service The type of the service that can be used to access the documents type : CodeableConcept 1..1 << Document Reference Service Type DocumentServiceType >> Where the service end-point version is located address : string 0..1 Parameter The name of 5.0.0 . For a parameter name : string 1..1 The value of the named parameter value : string 0..1 Context This full list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which available versions, see the procedure being documented is necessarily a "History and Physical" act event : CodeableConcept 0..* << This list Directory of codes represents the main clinical acts being documented DocumentEventType >> The time period over which the service that is described by the document was provided period : Period 0..1 published versions The kind of facility where the patient was seen facilityType . Page versions: R5 : CodeableConcept R4B 0..1 << XDS Facility Type DocumentFacilityType R4 >>

DocumentReference.status The status of the document reference http://hl7.org/fhir/document-reference-status DocumentReference.docStatus http://hl7.org/fhir/v3/vs/ActCode DocumentReference.context.facilityType XDS Facility Type Example http://hl7.org/fhir/vs/xds-facilitycodes
Pharmacy icon Fixed Work Group Maturity Level : N/A Standards Status of the underlying document Incomplete http://hl7.org/fhir/vs/composition-status DocumentReference.relatesTo.code The type of relationship between documents Fixed http://hl7.org/fhir/document-relationship-type DocumentReference.confidentiality Codes specifying the level of confidentiality of the composition Incomplete http://hl7.org/fhir/v3/vs/Confidentiality DocumentReference.primaryLanguage A human language Incomplete IETF language tag DocumentReference.mimeType The mime type of an attachment Incomplete BCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049) DocumentReference.service.type Document Reference Service Type Incomplete http://hl7.org/fhir/vs/documentreference-service-types DocumentReference.context.event This list of codes represents the main clinical acts being documented Incomplete : Informative

6.4.3.2 Constraints Inv-1 : A location or a service (or both) SHALL be provided (xpath: exists(f:location) or exists(f:service) ) 6.4.4 Implementation Notes The use of the .docStatus codes is discussed in the Composition description The resources maintain one way relationships that point backwards - e.g. the document that replaces one document points towards the document that it replaced. The reverse relationships can be followed by using indexes built from the resources. Typically, this is done using the search parameters described below. Given that documents may have other documents that replace or append them, clients should always check these relationships when accessing documents 6.4.4.1 Document Formats In addition to a mime type (which is mandatory), there is also a format element which carries a URI. This element has one or more identifiers that indicate that the format and/or content of the document conforms to additional rules beyond the base format indicated in the mimeType. This is most often used when the mime-type is text/xml, to provide additional information for finding the correct document. Defined URIs: ASTM CCR : urn:astm-org:CCR CCDA: urn:hl7-org:sdwg:ccda-level-1:1.1, urn:hl7-org:sdwg:ccda-level-2:1.1 and urn:hl7-org:sdwg:ccda-level-3:1.1 IHE defines URIs here and OIDs here (prefix OIDs with urn:oid: in the resource). Other URIs can be used for items not on this list. 6.4.4.2 Generating a Document Reference A client can ask a server to generate a document reference from a document. The server reads the existing document and generates a matching DocumentReference resource, or returns one it has previously generated. Servers may be able to return or generate document references for the following types of content: Type Comments FHIR Documents The uri refers to an existing Document CDA Document The uri is a reference to a Binary end-point that returns either a CDA document, or some kind of CDA Package that the server knows how to process (e.g. an IHE .zip) Other The server can be asked to generate a document reference page provides mappings for other kinds of documents. For some of these documents (e.g. PDF documents) a server could only provide a DocumentReference it is already existed, or the server had special knowledge of the document The server either returns a search result containing a single DocumentReference, or it returns an error. If some the URI refers to another server, it is at the discretion of the server whether to retrieve it or return an error. The operation is initiated by a named query, using _query=generate on the /DocumentReference end point: GET [service-url]/DocumentReference/?_query=generate&uri=:url&... The "uri" parameter is a relative or absolute reference ProductShelfLife (see Mappings 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 the server to decide) 6.4.5 Search Parameters Search parameters for this resource. The standard parameters also apply. See Searching Standards for more further information about searching in REST, messaging, and services. & status).

Name Type Description Paths _id token The logical resource id associated with the resource (must be supported by all servers) _language token The language of the resource authenticator reference Who/What authenticated the document DocumentReference.authenticator ( Organization , Practitioner ) author reference Who and/or what authored the document DocumentReference.author ( Device , Patient , Practitioner , RelatedPerson ) class token Categorization of Document DocumentReference.class confidentiality token Sensitivity of source document DocumentReference.confidentiality created date Document creation time DocumentReference.created custodian reference Org which maintains the document DocumentReference.custodian ( Organization ) description string Human-readable description (title) DocumentReference.description event token Main Clinical Acts Documented DocumentReference.context.event facility token Kind of facility where patient was seen DocumentReference.context.facilityType format token Format/content rules for the document DocumentReference.format identifier token Master Version Specific Identifier DocumentReference.masterIdentifier, DocumentReference.identifier indexed date When this document reference created DocumentReference.indexed language token The marked primary language for the document DocumentReference.primaryLanguage location string Where to access the document DocumentReference.location period date Time of service that is being documented DocumentReference.context.period 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 size number Size of the document in bytes DocumentReference.size status token current | superceded | entered in error DocumentReference.status subject reference Who|what is the subject of the document DocumentReference.subject ( Device , Patient , Practitioner , Group ) type token What kind of document this is (LOINC if possible) DocumentReference.type
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