Release 5 Preview #2

Documentreference-example.xml

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeCompartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Raw XML (canonical form + also see XML Format Specification)

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Generic example (id = "example")

<?xml version="1.0" encoding="UTF-8"?>

<DocumentReference xmlns="http://hl7.org/fhir">
  <id value="example"/> 
  <!--    Many XDS systems do not trak any id for the author. When systems don't do this, 
    the only option is for the author information to be contained in the Document Reference
      -->
  <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><p> <b> Generated Narrative</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> : <span> Outpatient Note</span> </p> <p> <b> category</b> : <span> History and Physical</span> </p> <p> <b> subject</b> : <a> Generated Summary: id: xcda; Medical record number = 12345 (USUAL); active; Henry Levin
           ; gender: male; birthDate: 1932-09-24</a> </p> <p> <b> date</b> : Dec 24, 2005 9:43:41 AM</p> <p> <b> author</b> : </p> <ul> <li> <a> Generated Summary: id: xcda1; D234123 (OFFICIAL); Sherry Dopplemeyer ; john.doe@healthcare.example.o
            rg</a> </li> <li> <a> id: a2; Gerald Smitty </a> </li> </ul> <p> <b> authenticator</b> : <a> Generated Summary: id: f001; 91654 (OFFICIAL), 17-0112278 (USUAL); <span> University Medical Hospital</span> ; name: Burgers University Medical Center; ph: 022-655 2300(WORK)</a> </p> <p> <b> custodian</b> : <a> Generated Summary: id: f001; 91654 (OFFICIAL), 17-0112278 (USUAL); <span> University Medical Hospital</span> ; name: Burgers University Medical Center; ph: 022-655 2300(WORK)</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> Generated Summary: id: example; urn:oid:1.3.6.1.4.1.21367.2005.3.7; urn:oid:1.3.6.1.4.1.21367.2005.3
              .7.1234; status: current; docStatus: preliminary; <span> Outpatient Note</span> ; <span> History and Physical</span> ; date: Dec 24, 2005 9:43:41 AM; description: Physical; <span> very restricted</span> </a> </td> </tr> </table> <p> <b> description</b> : Physical</p> <p> <b> securityLabel</b> : <span> 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> <span> History and Physical Specification</span> </td> </tr> </table> <h3> Contexts</h3> <table> <tr> <td> -</td> <td> <b> Encounter</b> </td> <td> <b> Event</b> </td> <td> <b> Period</b> </td> <td> <b> FacilityType</b> </td> <td> <b> PracticeSetting</b> </td> <td> <b> SourcePatientInfo</b> </td> <td> <b> Related</b> </td> </tr> <tr> <td> *</td> <td> <a> Generated Summary: id: xcda; 1234213.52345873 (OFFICIAL); status: completed; <span> ambulatory</span> ; <span> Arm</span> </a> </td> <td> <span> Arm</span> </td> <td> Dec 23, 2004 8:00:00 AM --&gt; Dec 23, 2004 8:01:00 AM</td> <td> <span> Outpatient</span> </td> <td> <span> General Medicine</span> </td> <td> <a> Generated Summary: id: xcda; Medical record number = 12345 (USUAL); active; Henry Levin
               ; gender: male; birthDate: 1932-09-24</a> </td> <td> <a> Generated Summary: id: xcda; Medical record number = 12345 (USUAL); active; Henry Levin
               ; gender: male; birthDate: 1932-09-24</a> </td> </tr> </table> </div> </text> <contained> 
    <Practitioner> 
      <id value="a2"/> 
      <name> 
        <family value="Smitty"/> 
        <given value="Gerald"/> 
      </name> 
    </Practitioner> 
  </contained> 
  <masterIdentifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7"/> 
  </masterIdentifier> 
  <identifier> 
    <system value="urn:ietf:rfc:3986"/> 
    <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"/> 
  </identifier> 
  <status value="current"/> 
  <docStatus value="preliminary"/> 

  <type> 
    <coding> 
      <system value="http://loinc.org"/> 
      <code value="34108-1"/> 
      <display value="Outpatient Note"/> 
    </coding> 
  </type> 
  <category> 
    <coding> 
      <system value="http://ihe.net/xds/connectathon/classCodes"/> 
      <code value="History and Physical"/> 
      <display value="History and Physical"/> 
    </coding> 
  </category> 
  <subject> 
    <reference value="Patient/xcda"/> 
  </subject> 
  <date value="2005-12-24T09:43:41+11:00"/> 
  <author> 
    <reference value="Practitioner/xcda1"/> 
  </author> 
  <author> 
    <reference value="#a2"/> 
  </author> 
  <authenticator> 
    <reference value="Organization/f001"/> 
  </authenticator> 
  <custodian> 
    <reference value="Organization/f001"/> 
  </custodian> 
  <relatesTo> 
    <code value="appends"/> 
    <target> 
      <reference value="DocumentReference/example"/> 
    </target> 
  </relatesTo> 
  <description value="Physical"/> 
  <securityLabel> 
    <coding> 
      <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality"/> 
      <code value="V"/> 
      <display value="very restricted"/> 
    </coding> 
  </securityLabel> 
  <content> 
    <attachment> 
      <contentType value="application/hl7-v3+xml"/> 
      <language value="en-US"/> 
      <url value="http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510"/> 
      <size value="3654"/> 
      <hash value="2jmj7l5rSw0yVb/vlWAYkK/YBwk="/> 
      <title value="Physical"/> 
           <creation value="2005-12-24T09:35:00+11:00"/> 
    </attachment> 
    <format> 
      <system value="urn:oid:1.3.6.1.4.1.19376.1.2.3"/> 
      <code value="urn:ihe:pcc:handp:2008"/> 
      <display value="History and Physical Specification"/> 
    </format> 
  </content> 
  <context> 
    <encounter> 
      <reference value="Encounter/xcda"/> 
    </encounter> 
    <event> 
      <coding> 
        <system value="http://ihe.net/xds/connectathon/eventCodes"/> 
        <code value="T-D8200"/> 
        <display value="Arm"/> 
      </coding> 
    </event> 
    <period> 
      <start value="2004-12-23T08:00:00+11:00"/> 
      <end value="2004-12-23T08:01:00+11:00"/> 
    </period> 
    <facilityType> 
      <coding> 
        <system value="http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes"/> 
        <code value="Outpatient"/> 
        <display value="Outpatient"/> 
      </coding> 
    </facilityType> 
    <practiceSetting> 
      <coding> 
        <system value="http://www.ihe.net/xds/connectathon/practiceSettingCodes"/> 
        <code value="General Medicine"/> 
        <display value="General Medicine"/> 
      </coding> 
    </practiceSetting> 
    <sourcePatientInfo> 
      <reference value="Patient/xcda"/> 
    </sourcePatientInfo> 
    <related> 
      <reference value="Patient/xcda"/> 
      <identifier> 
        <system value="urn:ietf:rfc:3986"/> 
        <value value="urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"/> 
      </identifier> 
    </related> 
  </context> 
</DocumentReference> 

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.