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10.2 Resource DocumentReference - Content

Orders and Observations icon Work GroupMaturity Level: 5 Trial UseSecurity Category: Not Classified Compartments: Device, Encounter, Group, Patient, Practitioner, RelatedPerson

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.

10.2.1 Scope and Usage

A DocumentReference resource is used to index a document, clinical note, and other binary objects such as a photo, video, or audio recording, including those resulting from diagnostic or care provision procedures, to make them available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be presented to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type and that conforms to this definition.

Typically, DocumentReference resources are used in document indexing systems, such as IHE XDS icon and as profiled in IHE Mobile Access to Health Documents icon.

DocumentReference contains metadata, inline content or direct references to documents such as:

  • CDA icon documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents icon, Scanned Paper, and digital records of faxes
  • Clinical Notes in various forms
  • Image files (e.g., JPEG, GIF, TIFF)
  • Video files (e.g., MP4, WMV)
  • Audio files (e.g., WAV, MP3)
  • Non-Standard formats (e.g., CSV, RTF, WORD)
  • Other kinds of documents, such as records of prescriptions or immunizations

10.2.2 Boundaries and Relationships

This resource captures data that might not be in FHIR format. The document can be any object (e.g. file), and is not limited to the formal HL7 definitions of Document. This resource may be a report with unstructured text or a report that is not expressed in a DiagnosticReport. The DiagnosticReport is appropriate to reflect a set of discrete results (Observations) and associated contextual details for a specific report, and within those results any further structure within the Observation instances. The DocumentReference resource may be an Observation whose value is audio, video or image data. This resource is the preferred representation of such forms of information as it exposes the metadata relevant for interpreting the information. There is some overlap potential such as a scan of a CBC report that can either be referenced by way of a DocumentReference, or included in a DiagnosticReport as a presentedForm together with the structured, discrete data. In some cases, a single in-system entity may be represented as both resources if they provide relevant metadata or workflow-specific attributes. Specific implementation guides would further clarify which approach is more appropriate.

This resource is able to contain medical images in a DICOM format. These images may also be made accessible through an ImagingStudy or ImagingSelection resource, which provides a direct reference to the image to a WADO-RS server. For such images, the WADO-RS framework is a preferred method for representing the images - the WADO-RS service may include rendering the image with annotations and display parameters from an associated DICOM presentation state, for instance. On the other hand, the DocumentReference resource allows for a robust transfer of an image across boundaries where the WADO-RS service is not available. For this reason, medical images can also be represented in a DocumentReference resource, but the DocumentReference.content.attachment.url should provide a reference to a source WADO-RS service for the image.

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. DocumentReference is intended for general references to any type of media file including assembled documents.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource, or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet icon, or a DICOM WADO-RS exchange, or an HL7 V2 icon message query - though the way each of these service calls works must be specified in some external standard or other documentation.

A DocumentReference describes some other document. This means that there are two sets of provenance information relevant here: the provenance of the document, and the provenance of the document reference. Sometimes, the provenance information is closely related, as when the document producer also produces the document reference, but in other workflows, the document reference is generated later by other actors. In the DocumentReference resource, the meta content refers to the provenance of the reference itself, while the content described below concerns the document it references. Like all resources, there is overlap between the information in the resource directly, and in the general Provenance resource. This is discussed as part of the description of the Provenance resource.

10.2.3 References to this Resource

10.2.4 Resource Content

Structure

NameFlagsCard.TypeDescription & Constraintsdoco
.. 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

... 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 icon (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(Any) Main clinical acts documented
Binding: v3 Code System ActCode icon (Example)

... related 0..* Reference(Any) Related identifiers or resources associated with the document reference

... 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 dateTime When this document reference was created
... author Σ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam | Group) 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 | Group) 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 icon (Preferred)
...... valueCoding Coding
...... valueUri uri
...... valueCanonical canonical()

doco Documentation for this format icon

See the Extensions for this resource

 

Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis

10.2.4.1 Terminology Bindings

Path ValueSet Type Documentation
DocumentReference.status DocumentReferenceStatus Required

The status of the document reference.
DocumentReference.docStatus CompositionStatus Required

The workflow/clinical status of the composition.
DocumentReference.modality Modality icon Extensible

Transitive closure of CID 33 Modality
DocumentReference.type FHIRDocumentTypeCodes Preferred

FHIR Document Codes - all LOINC codes where scale type = 'DOC'.
DocumentReference.category ReferencedItemCategoryValueSet Example

This is the code specifying the high-level kind of document (e.g. Prescription, Discharge Summary, Report, etc.). Made up of a set of non-healthcare specific codes and all LOINC codes where scale type = 'DOC'.
DocumentReference.event ActCode icon Example

A code specifying the particular kind of Act that the Act-instance represents within its class. Constraints: The kind of Act (e.g. physical examination, serum potassium, inpatient encounter, charge financial transaction, etc.) is specified with a code from one of several, typically external, coding systems. The coding system will depend on the class of Act, such as LOINC for observations, etc. Conceptually, the Act.code must be a specialization of the Act.classCode. This is why the structure of ActClass domain should be reflected in the superstructure of the ActCode domain and then individual codes or externally referenced vocabularies subordinated under these domains that reflect the ActClass structure. Act.classCode and Act.code are not modifiers of each other but the Act.code concept should really imply the Act.classCode concept. For a negative example, it is not appropriate to use an Act.code "potassium" together with and Act.classCode for "laboratory observation" to somehow mean "potassium laboratory observation" and then use the same Act.code for "potassium" together with Act.classCode for "medication" to mean "substitution of potassium". This mutually modifying use of Act.code and Act.classCode is not permitted.
DocumentReference.bodySite SNOMEDCTBodyStructures Example

This value set includes all codes from SNOMED CT icon where concept is-a 442083009 (Anatomical or acquired body site (body structure)).
DocumentReference.facilityType FacilityTypeCodeValueSet Example

This is the code representing the type of organizational setting where the clinical encounter, service, interaction, or treatment occurred. The value set used for Healthcare Facility Type has been defined by HITSP to be the value set reproduced from HITSP C80 Table 2-147.
DocumentReference.practiceSetting PracticeSettingCodeValueSet Example

This is the code representing the clinical specialty of the clinician or provider who interacted with, treated, or provided a service to/for the patient. The value set used for clinical specialty has been limited by HITSP to the value set reproduced from HITSP C80 Table 2-149 Clinical Specialty Value Set Definition.
DocumentReference.attester.mode CompositionAttestationMode Preferred

The way in which a person authenticated a composition.
DocumentReference.relatesTo.code DocumentRelationshipType Extensible

The type of relationship between documents.
DocumentReference.securityLabel SecurityLabelExamples Example

A sample of security labels from Healthcare Privacy and Security Classification System as the combination of data and event codes.
DocumentReference.content.profile.value[x] HL7FormatCodes icon Preferred

The HL7-FormatCodes value set is defined to be the set of FormatCode(s) defined by implementation guides published by HL7 and other SDOs. The use of a formatCode from the FormatCodes value set specifies the technical format that a document conforms to. The formatCode is a further specialization more detailed than the mime-type. The formatCode provides sufficient information to allow any potential document content consumer to know if it can process and/or display the content of the document based on the document encoding, structure and template conformance indicated by the formatCode. The set of formatCodes is intended to be extensible. The Content Logical Description is defined intentionally to permit formatCodes defined by other Standards Development Organizations to be added by inclusion of additional formatCode Code Systems.

10.2.4.2 Constraints

UniqueKeyLevelLocationDescriptionExpression
img docRef-1Warning (base)facilityType SHALL only be present if context is not an encounterfacilityType.empty() or context.where(resolve() is Encounter).empty()
img docRef-2Warning (base)practiceSetting SHALL only be present if context is not presentpracticeSetting.empty() or context.where(resolve() is Encounter).empty()

10.2.5 Implementation Notes

  • The resources maintain one way relationships that point backwards - e.g., the document that replaces one document points towards the document that it replaced. The reverse relationships can be followed by using indexes built from the resources. Typically, this is done using the search parameters described below. Given that documents may have other documents that replace or append them, clients should always check these relationships when accessing documents
  • The _content search parameter shall search across the DocumentReference.content.attachment.data, and DocumentReference.content.attachment.url.
  • If the referenced resource changes, then the corresponding DocumentReference may be out of sync temporarily. Coordination will be needed to ensure that the DocumentReference gets updated if the referenced resource changes (and to not allow updates to the DocumentReference that cause it to be misaligned with the referenced resource).
  • DocumentReference might be appropriate for including a rendered DICOM image in cases where the full image context is not important. When this is done, the DocumentReference.event.reference should point at the ImagingStudy or ImagingSelection.

10.2.6 Search Parameters

Search parameters for this resource. See also the full list of search parameters for this resource, and check the Extensions registry for search parameters on extensions related to this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
attester reference Who attested the document DocumentReference.attester.party
(Practitioner, Group, Organization, Patient, PractitionerRole, RelatedPerson)
author reference Who and/or what authored the document DocumentReference.author
(Practitioner, Group, Organization, CareTeam, Device, Patient, PractitionerRole, RelatedPerson)
based-on reference Procedure that caused this media to be created DocumentReference.basedOn
(Appointment, MedicationRequest, RequestOrchestration, VisionPrescription, ServiceRequest, SupplyRequest, AppointmentResponse, CoverageEligibilityRequest, CarePlan, EnrollmentRequest, NutritionOrder, DeviceRequest, Contract, Claim, CommunicationRequest, ImmunizationRecommendation)
bodysite token The body site studied DocumentReference.bodySite.concept
bodysite-reference reference The body site studied DocumentReference.bodySite.reference
category token Categorization of document DocumentReference.category
contenttype token Mime type of the content, with charset etc. DocumentReference.content.attachment.contentType
context reference Context of the document content DocumentReference.context
(Appointment, EpisodeOfCare, Encounter)
creation date Date attachment was first created DocumentReference.content.attachment.creation
custodian reference Organization which maintains the document DocumentReference.custodian
(Organization)
date date When this document reference was created DocumentReference.date 26 Resources
description string Human-readable description DocumentReference.description
doc-status token preliminary | final | amended | entered-in-error DocumentReference.docStatus
event-code token Main clinical acts documented DocumentReference.event.concept
event-reference reference Main clinical acts documented DocumentReference.event.reference
facility token Kind of facility where patient was seen DocumentReference.facilityType
format-canonical uri Profile canonical content rules for the document (DocumentReference.content.profile.value.ofType(canonical))
format-code token Format code content rules for the document (DocumentReference.content.profile.value.ofType(Coding))
format-uri uri Profile URI content rules for the document (DocumentReference.content.profile.value.ofType(uri))
identifier token Identifier of the attachment binary DocumentReference.identifier 65 Resources
language token Human language of the content (BCP-47) DocumentReference.content.attachment.language
location uri Uri where the data can be found DocumentReference.content.attachment.url
modality token The modality used DocumentReference.modality
patient reference Who/what is the subject of the document DocumentReference.subject.where(resolve() is Patient)
(Patient)		 65 Resources
period date Time of service that is being documented DocumentReference.period
related reference Related identifiers or resources DocumentReference.related
(Any)
relatesto reference Target of the relationship DocumentReference.relatesTo.target
(DocumentReference)
relation token replaces | transforms | signs | appends DocumentReference.relatesTo.code
relationship composite Combination of relation and relatesTo On DocumentReference.relatesTo:
  relatesto: target
  relation: code
security-label token Document security-tags DocumentReference.securityLabel
setting token Additional details about where the content was created (e.g. clinical specialty) DocumentReference.practiceSetting
status token current | superseded | entered-in-error DocumentReference.status
subject reference Who/what is the subject of the document DocumentReference.subject
(Any)
type token Kind of document (LOINC if possible) DocumentReference.type 11 Resources
version string The business version identifier DocumentReference.version