DSTU2 FHIR Release 3 (STU)

This page is part of the FHIR Specification (v1.0.2: DSTU (v3.0.2: STU 2). 3). 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 R3 R2

Documentreference-example.json

Structured Documents Work Group Maturity Level : N/A Ballot Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Raw JSON ( canonical form )

Example of documentreference Generic example

{
  "resourceType": "DocumentReference",
  "id": "example",
  "text": {
    "fhir_comments": [
      "   Many XDS systems do not trak any id for the author. When systems don't do this, \n    the only option is for the author information to be contained in the Document Reference   "
    ],

    "status": "generated",
    "div": "<div><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>contained</b>: </p><p><b>masterIdentifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7</p><p><b>identifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p><p><b>subject</b>: <a>Patient/xcda</a></p><p><b>type</b>: Outpatient Note <span>(Details : {LOINC code '34108-1' = 'Outpatient Note', given as 'Outpatient Note'})</span></p><p><b>class</b>: History and Physical <span>(Details : {http://ihe.net/xds/connectathon/classCodes code 'History and Physical' = '??', given as 'History and Physical'})</span></p><p><b>author</b>: <a>Practitioner/xcda1</a>, id: a2; Gerald Smitty </p><p><b>custodian</b>: <a>Organization/organization-example</a></p><p><b>authenticator</b>: <a>Organization/organization-example</a></p><p><b>created</b>: 24/12/2005 9:35:00 AM</p><p><b>indexed</b>: 24/12/2005 9:43:41 AM</p><p><b>status</b>: current</p><p><b>docStatus</b>: preliminary <span>(Details : {http://hl7.org/fhir/composition-status code 'preliminary' = 'Preliminary', given as 'preliminary'})</span></p><h3>RelatesTos</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>appends</td><td><a>DocumentReference/example</a></td></tr></table><p><b>description</b>: Physical</p><p><b>securityLabel</b>: very restricted <span>(Details : {http://hl7.org/fhir/v3/Confidentiality code 'V' = 'very restricted', given as 'very restricted'})</span></p><h3>Contents</h3><table><tr><td>-</td><td><b>Attachment</b></td><td><b>Format</b></td></tr><tr><td>*</td><td/><td>History and Physical Specification (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:ihe:pcc:handp:2008 = '??', stated as 'History and Physical Specification')</td></tr></table><blockquote><p><b>context</b></p><p><b>encounter</b>: <a>Encounter/xcda</a></p><p><b>event</b>: Arm <span>(Details : {http://ihe.net/xds/connectathon/eventCodes code 'T-D8200' = '??', given as 'Arm'})</span></p><p><b>period</b>: 23/12/2004 8:00:00 AM --&gt; 23/12/2004 8:01:00 AM</p><p><b>facilityType</b>: Outpatient <span>(Details : {http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes code 'Outpatient' = '??', given as 'Outpatient'})</span></p><p><b>practiceSetting</b>: General Medicine <span>(Details : {http://www.ihe.net/xds/connectathon/practiceSettingCodes code 'General Medicine' = '??', given as 'General Medicine'})</span></p><p><b>sourcePatientInfo</b>: <a>Patient/xcda</a></p><h3>Relateds</h3><table><tr><td>-</td><td><b>Identifier</b></td><td><b>Ref</b></td></tr><tr><td>*</td><td>urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345</td><td><a>Patient/xcda</a></td></tr></table></blockquote></div>"

    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>contained</b>: </p><p><b>masterIdentifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7</p><p><b>identifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p><p><b>status</b>: current</p><p><b>docStatus</b>: preliminary</p><p><b>type</b>: Outpatient Note <span>(Details : {LOINC code '34108-1' = 'Outpatient Note', given as 'Outpatient Note'})</span></p><p><b>class</b>: History and Physical <span>(Details : {http://ihe.net/xds/connectathon/classCodes code 'History and Physical' = 'History and Physical', given as 'History and Physical'})</span></p><p><b>subject</b>: <a>Patient/xcda</a></p><p><b>created</b>: 24/12/2005 9:35:00 AM</p><p><b>indexed</b>: 24/12/2005 9:43:41 AM</p><p><b>author</b>: <a>Practitioner/xcda1</a>, id: a2; Gerald Smitty </p><p><b>authenticator</b>: <a>Organization/f001</a></p><p><b>custodian</b>: <a>Organization/f001</a></p><h3>RelatesTos</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>appends</td><td><a>DocumentReference/example</a></td></tr></table><p><b>description</b>: Physical</p><p><b>securityLabel</b>: very restricted <span>(Details : {http://hl7.org/fhir/v3/Confidentiality code 'V' = 'very restricted', given as 'very restricted'})</span></p><h3>Contents</h3><table><tr><td>-</td><td><b>Attachment</b></td><td><b>Format</b></td></tr><tr><td>*</td><td/><td>History and Physical Specification (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:ihe:pcc:handp:2008 = 'urn:ihe:pcc:handp:2008', stated as 'History and Physical Specification')</td></tr></table><blockquote><p><b>context</b></p><p><b>encounter</b>: <a>Encounter/xcda</a></p><p><b>event</b>: Arm <span>(Details : {http://ihe.net/xds/connectathon/eventCodes code 'T-D8200' = 'T-D8200', given as 'Arm'})</span></p><p><b>period</b>: 23/12/2004 8:00:00 AM --&gt; 23/12/2004 8:01:00 AM</p><p><b>facilityType</b>: Outpatient <span>(Details : {http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes code 'Outpatient' = 'Outpatient', given as 'Outpatient'})</span></p><p><b>practiceSetting</b>: General Medicine <span>(Details : {http://www.ihe.net/xds/connectathon/practiceSettingCodes code 'General Medicine' = 'General Medicine', given as 'General Medicine'})</span></p><p><b>sourcePatientInfo</b>: <a>Patient/xcda</a></p><h3>Relateds</h3><table><tr><td>-</td><td><b>Identifier</b></td><td><b>Ref</b></td></tr><tr><td>*</td><td>urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345</td><td><a>Patient/xcda</a></td></tr></table></blockquote></div>"

  },
  "contained": [
    {
      "resourceType": "Practitioner",
      "id": "a2",
      "name": {
        "family": [
          "Smitty"
        ],
        "given": [
          "Gerald"
        ]
      },
      "practitionerRole": [

      "name": [

        {
          "managingOrganization": {
            "display": "Cleveland Clinic"
          },
          "role": {
            "text": "Attending"
          },
          "specialty": [
            {
              "text": "Orthopedic"
            }

          "family": "Smitty",
          "given": [
            "Gerald"

          ]
        }
      ]
    }
  ],
  "masterIdentifier": {
    "system": "urn:ietf:rfc:3986",
    "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7"
  },
  "identifier": [
    {
      "system": "urn:ietf:rfc:3986",
      "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"
    }
  ],
  "subject": {
    "reference": "Patient/xcda"
  },

  "status": "current",
  "docStatus": "preliminary",

  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34108-1",
        "display": "Outpatient Note"
      }
    ]
  },
  "class": {
    "coding": [
      {
        "system": "http://ihe.net/xds/connectathon/classCodes",
        "code": "History and Physical",
        "display": "History and Physical"
      }
    ]
  },
  "subject": {
    "reference": "Patient/xcda"
  },
  "created": "2005-12-24T09:35:00+11:00",
  "indexed": "2005-12-24T09:43:41+11:00",

  "author": [
    {
      "reference": "Practitioner/xcda1"
    },
    {
      "reference": "#a2"
    }
  ],
  "custodian": {
    "reference": "Organization/organization-example"
  },

  "authenticator": {
    "reference": "Organization/organization-example"

    "reference": "Organization/f001"

  },
  "created": "2005-12-24T09:35:00+11:00",
  "indexed": "2005-12-24T09:43:41+11:00",
  "status": "current",
  "docStatus": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/composition-status",
        "code": "preliminary",
        "display": "preliminary"
      }
    ]

  "custodian": {
    "reference": "Organization/f001"

  },
  "relatesTo": [
    {
      "code": "appends",
      "target": {
        "reference": "DocumentReference/example"
      }
    }
  ],
  "description": "Physical",
  "securityLabel": [
    {
      "coding": [
        {
          "system": "http://hl7.org/fhir/v3/Confidentiality",
          "code": "V",
          "display": "very restricted"
        }
      ]
    }
  ],
  "content": [
    {
      "attachment": {
        "contentType": "application/hl7-v3+xml",
        "language": "en-US",
        "url": "http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510",
        "size": 3654,
        "hash": "2jmj7l5rSw0yVb/vlWAYkK/YBwk="
      },
      "format": [
        {
          "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
          "code": "urn:ihe:pcc:handp:2008",
          "display": "History and Physical Specification"
        }
      ]

      "format": {
        "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
        "code": "urn:ihe:pcc:handp:2008",
        "display": "History and Physical Specification"
      }

    }
  ],
  "context": {
    "encounter": {
      "reference": "Encounter/xcda"
    },
    "event": [
      {
        "coding": [
          {
            "system": "http://ihe.net/xds/connectathon/eventCodes",
            "code": "T-D8200",
            "display": "Arm"
          }
        ]
      }
    ],
    "period": {
      "start": "2004-12-23T08:00:00+11:00",
      "end": "2004-12-23T08:01:00+11:00"
    },
    "facilityType": {
      "coding": [
        {
          "system": "http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes",
          "code": "Outpatient",
          "display": "Outpatient"
        }
      ]
    },
    "practiceSetting": {
      "coding": [
        {
          "system": "http://www.ihe.net/xds/connectathon/practiceSettingCodes",
          "code": "General Medicine",
          "display": "General Medicine"
        }
      ]
    },
    "sourcePatientInfo": {
      "reference": "Patient/xcda"
    },
    "related": [
      {
        "identifier": {
          "system": "urn:ietf:rfc:3986",
          "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"
        },
        "ref": {
          "reference": "Patient/xcda"
        }
      }
    ]
  }
}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.