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Structured Documents Work GroupMaturity Level: 3 Trial UseSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the DocumentReference resource.

DocumentReference
Element IdDocumentReference
Definition

A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

Cardinality0..*
TypeDomainResource
Comments

Usually, this is used for documents other than those defined by FHIR.

DocumentReference.masterIdentifier
Element IdDocumentReference.masterIdentifier
Definition

Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.

Cardinality0..1
TypeIdentifier
Requirements

The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

Summarytrue
Comments

CDA Document Id extension and root.

DocumentReference.identifier
Element IdDocumentReference.identifier
Definition

Other identifiers associated with the document, including version independent identifiers.

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Summarytrue
DocumentReference.status
Element IdDocumentReference.status
Definition

The status of this document reference.

Cardinality1..1
Terminology BindingDocumentReferenceStatus (Required)
Typecode
Is Modifiertrue (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summarytrue
Comments

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

DocumentReference.docStatus
Element IdDocumentReference.docStatus
Definition

The status of the underlying document.

Cardinality0..1
Terminology BindingCompositionStatus (Required)
Typecode
Summarytrue
Comments

The document that is pointed to might be in various lifecycle states.

DocumentReference.type
Element IdDocumentReference.type
Definition

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.

Cardinality0..1
Terminology BindingDocument Type Value Set (Preferred)
TypeCodeableConcept
Summarytrue
Comments

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

DocumentReference.category
Element IdDocumentReference.category
Definition

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.

Cardinality0..*
Terminology BindingDocument Class Value Set (Example)
TypeCodeableConcept
Alternate Namesclaxs
Summarytrue
Comments

Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

DocumentReference.subject
Element IdDocumentReference.subject
Definition

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).

Cardinality0..1
TypeReference(Patient | Practitioner | Group | Device)
Summarytrue
DocumentReference.date
Element IdDocumentReference.date
Definition

When the document reference was created.

Cardinality0..1
Typeinstant
Alternate Namesindexed
Summarytrue
Comments

Referencing/indexing time is used for tracking, organizing versions and searching.

DocumentReference.author
Element IdDocumentReference.author
Definition

Identifies who is responsible for adding the information to the document.

Cardinality0..*
TypeReference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)
Summarytrue
Comments

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

DocumentReference.authenticator
Element IdDocumentReference.authenticator
Definition

Which person or organization authenticates that this document is valid.

Cardinality0..1
TypeReference(Practitioner | PractitionerRole | Organization)
Comments

Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.

DocumentReference.custodian
Element IdDocumentReference.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Cardinality0..1
TypeReference(Organization)
Comments

Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

DocumentReference.relatesTo
Element IdDocumentReference.relatesTo
Definition

Relationships that this document has with other document references that already exist.

Cardinality0..*
Summarytrue
Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

DocumentReference.relatesTo.code
Element IdDocumentReference.relatesTo.code
Definition

The type of relationship that this document has with anther document.

Cardinality1..1
Terminology BindingDocumentRelationshipType (Required)
Typecode
Summarytrue
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

DocumentReference.relatesTo.target
Element IdDocumentReference.relatesTo.target
Definition

The target document of this relationship.

Cardinality1..1
TypeReference(DocumentReference)
Summarytrue
DocumentReference.description
Element IdDocumentReference.description
Definition

Human-readable description of the source document.

Cardinality0..1
Typestring
Requirements

Helps humans to assess whether the document is of interest.

Summarytrue
Comments

What the document is about, a terse summary of the document.

DocumentReference.securityLabel
Element IdDocumentReference.securityLabel
Definition

A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.

Cardinality0..*
Terminology BindingSecurityLabels (Extensible)
TypeCodeableConcept
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Summarytrue
Comments

The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

DocumentReference.content
Element IdDocumentReference.content
Definition

The document and format referenced. There may be multiple content element repetitions, each with a different format.

Cardinality1..*
Summarytrue
DocumentReference.content.attachment
Element IdDocumentReference.content.attachment
Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Cardinality1..1
TypeAttachment
Summarytrue
DocumentReference.content.format
Element IdDocumentReference.content.format
Definition

An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Cardinality0..1
Terminology BindingDocumentReference Format Code Set (Preferred)
TypeCoding
Summarytrue
Comments

Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

DocumentReference.context
Element IdDocumentReference.context
Definition

The clinical context in which the document was prepared.

Cardinality0..1
Summarytrue
Comments

These values are primarily added to help with searching for interesting/relevant documents.

DocumentReference.context.encounter
Element IdDocumentReference.context.encounter
Definition

Describes the clinical encounter or type of care that the document content is associated with.

Cardinality0..*
TypeReference(Encounter | EpisodeOfCare)
DocumentReference.context.event
Element IdDocumentReference.context.event
Definition

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.

Cardinality0..*
Terminology Bindingv3 Code System ActCode (Example)
TypeCodeableConcept
Comments

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

DocumentReference.context.period
Element IdDocumentReference.context.period
Definition

The time period over which the service that is described by the document was provided.

Cardinality0..1
TypePeriod
Summarytrue
DocumentReference.context.facilityType
Element IdDocumentReference.context.facilityType
Definition

The kind of facility where the patient was seen.

Cardinality0..1
Terminology BindingFacility Type Code Value Set (Example)
TypeCodeableConcept
DocumentReference.context.practiceSetting
Element IdDocumentReference.context.practiceSetting
Definition

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Cardinality0..1
Terminology BindingPractice Setting Code Value Set (Example)
TypeCodeableConcept
Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Comments

This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

DocumentReference.context.sourcePatientInfo
Element IdDocumentReference.context.sourcePatientInfo
Definition

The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Cardinality0..1
TypeReference(Patient)
DocumentReference.context.related
Element IdDocumentReference.context.related
Definition

Related identifiers or resources associated with the DocumentReference.

Cardinality0..*
TypeReference(Any)
Comments

May be identifiers or resources that caused the DocumentReference or referenced Document to be created.