Release 5 Draft Ballot

This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions

Orders and Observations 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. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy 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.

Cardinality0..*
TypeDomainResource
Summaryfalse
Comments

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

Invariants
Defined on this element
docRef-1Warning facilityType SHALL only be present if context is not an encounterfacilityType.empty() or context.where(resolve() is Encounter).empty()
docRef-2Warning practiceSetting SHALL only be present if context is not presentpracticeSetting.empty() or context.where(resolve() is Encounter).empty()
DocumentReference.identifier
Element IdDocumentReference.identifier
Definition

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

NoteThis is a business identifier, not a resource identifier (see discussion)
Cardinality0..*
TypeIdentifier
Requirements

Document identifiers usually assigned by the source of the document, or other business identifiers such as XDS DocumentEntry.uniqueId and DocumentEntry.entryUUID. These identifiers are specific to this instance of the document.

Summarytrue
Comments

The structure and format of this identifier would be consistent with the specification corresponding to the format of the document. (e.g. for a DICOM standard document, a 64-character numeric UID; for an HL7 CDA format, the CDA Document Id root and extension).

DocumentReference.basedOn
Element IdDocumentReference.basedOn
Definition

A procedure that is fulfilled in whole or in part by the creation of this media.

Cardinality0..*
TypeReference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | EpisodeOfCare | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestGroup | ServiceRequest | SupplyRequest | VisionPrescription)
Requirements

Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

Alternate Namesfulfills
Summaryfalse
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 BindingFHIR Document Type Codes (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 BindingReferenced Item Category Value Set (Example)
TypeCodeableConcept
Alternate Namesclass; classCode
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(Any)
Summarytrue
DocumentReference.context
Element IdDocumentReference.context
Definition

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

Cardinality0..*
TypeReference(Appointment | Encounter | EpisodeOfCare)
Summaryfalse
DocumentReference.event
Element IdDocumentReference.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)
TypeCodeableReference
Summaryfalse
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.facilityType
Element IdDocumentReference.facilityType
Definition

The kind of facility where the patient was seen.

Cardinality0..1
Terminology BindingDocumentC80FacilityType :
TypeCodeableConcept
Summaryfalse
DocumentReference.practiceSetting
Element IdDocumentReference.practiceSetting
Definition

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

Cardinality0..1
Terminology BindingDocumentC80PracticeSetting :
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.

Summaryfalse
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.period
Element IdDocumentReference.period
Definition

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

Cardinality0..1
TypePeriod
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 | CareTeam)
Summarytrue
Comments

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

DocumentReference.attester
Element IdDocumentReference.attester
Definition

A participant who has authenticated the accuracy of the document.

Cardinality0..*
Requirements

Identifies responsibility for the accuracy of the document content.

Summaryfalse
Comments

Only list each attester once.

DocumentReference.attester.mode
Element IdDocumentReference.attester.mode
Definition

The type of attestation the authenticator offers.

Cardinality1..1
Terminology BindingCompositionAttestationMode (Preferred)
TypeCodeableConcept
Requirements

Indicates the level of authority of the attestation.

Summaryfalse
DocumentReference.attester.time
Element IdDocumentReference.attester.time
Definition

When the document was attested by the party.

Cardinality0..1
TypedateTime
Requirements

Identifies when the information in the document was deemed accurate. (Things may have changed since then.).

Summaryfalse
DocumentReference.attester.party
Element IdDocumentReference.attester.party
Definition

Who attested the document in the specified way.

Cardinality0..1
TypeReference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
Requirements

Identifies who has taken on the responsibility for accuracy of the document content.

Summaryfalse
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)
Summaryfalse
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 (Extensible)
TypeCodeableConcept
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
Typemarkdown
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 found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the data elements in DocumentReference, while DocumentReference.securityLabel contains the security labels for the document the reference refers 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.

Cardinality0..*
Terminology BindingExample set of Security Labels (Example)
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. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata.

Cardinality1..*
Requirements

Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

Summarytrue
Comments

content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

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.profile
Element IdDocumentReference.content.profile
Definition

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

Cardinality0..*
Alternate Namesformat; formatCode
Summarytrue
Comments

Note that IHE often issues URNs for formatCode codes, not all documents can be identified by a URI.

For FHIR content, .profile should indicate the structureDefinition profile canonical URI(s) that the content complies with.

DocumentReference.content.profile.value[x]
Element IdDocumentReference.content.profile.value[x]
Definition

Code|uri|canonical.

Cardinality1..1
Terminology BindingHL7 ValueSet of Format Codes for use with Document Sharing (Preferred)
TypeCoding|uri|canonical
[x] NoteSee Choice of Data Types for further information about how to use [x]
Summarytrue