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
.
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list
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see
the
Directory
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versions:
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R4B
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R2
R3
R2
| Structured Documents Work Group | Maturity Level : N/A | Ballot Status : Informative | Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson |
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 --> 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 --> 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.