Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | TU | DomainResource | A reference to a document + Warning: facilityType SHALL only be present if context is not an encounter + Warning: practiceSetting SHALL only be present if context is not present Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension | |
identifier | Σ | 0..* | Identifier | Business identifiers for the document |
version | Σ | 0..1 | string | An explicitly assigned identifier of a variation of the content in the DocumentReference |
basedOn | 0..* | Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription) | Procedure that caused this media to be created | |
status | ?!Σ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (Required) |
docStatus | ?!Σ | 0..1 | code | registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown Binding: Composition Status (Required) |
modality | Σ | 0..* | CodeableConcept | Imaging modality used Binding: Modality (Extensible) |
type | Σ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: FHIR Document Type Codes (Preferred) |
category | Σ | 0..* | CodeableConcept | Categorization of document Binding: Referenced Item Category Value Set (Example) |
subject | Σ | 0..1 | Reference(Any) | Who/what is the subject of the document |
context | ΣC | 0..* | Reference(Appointment | Encounter | EpisodeOfCare) | Encounter the document reference is part of |
event | 0..* | CodeableReference() | Main clinical acts documented Binding: v3 Code System ActCode (Example) | |
bodySite | Σ | 0..* | CodeableReference(BodyStructure) | Body part included Binding: SNOMED CT Body Structures (Example) |
facilityType | C | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: Facility Type Code Value Set (Example) |
practiceSetting | C | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: Practice Setting Code Value Set (Example) |
period | Σ | 0..1 | Period | Time of service that is being documented |
date | Σ | 0..1 | instant | When this document reference was created |
author | Σ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam) | Who and/or what authored the document |
attester | 0..* | BackboneElement | Attests to accuracy of the document | |
mode | 1..1 | CodeableConcept | personal | professional | legal | official Binding: Composition Attestation Mode (Preferred) | |
time | 0..1 | dateTime | When the document was attested | |
party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the document | |
custodian | 0..1 | Reference(Organization) | Organization which maintains the document | |
relatesTo | Σ | 0..* | BackboneElement | Relationships to other documents |
code | Σ | 1..1 | CodeableConcept | The relationship type with another document Binding: Document Relationship Type (Extensible) |
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship |
description | Σ | 0..1 | markdown | Human-readable description |
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: Example set of Security Labels (Example) |
content | Σ | 1..* | BackboneElement | Document referenced |
attachment | Σ | 1..1 | Attachment | Where to access the document |
profile | Σ | 0..* | BackboneElement | Content profile rules for the document |
value[x] | Σ | 1..1 | Code|uri|canonical Binding: HL7 ValueSet of Format Codes for use with Document Sharing (Preferred) | |
valueCoding | Coding | |||
valueUri | uri | |||
valueCanonical | canonical() | |||
Documentation for this format |