{
  "resourceType": "Provenance",
  "id": "example",
  "target": [
    {
      "reference": "Procedure/example/_history/1"
    }
  ],
  "occurredPeriod": {
    "start": "2015-06-27",
    "end": "2015-06-28"
  },
  "recorded": "2015-06-27T08:39:24+10:00",
  "policy": [
    "http://acme.com/fhir/Consent/25"
  ],
  "location": {
    "reference": "Location/1"
  },
  "activity": {
    "coding": [
      {
        "system": "http://snomed.info/sct",
        "code": "3457005",
        "display": "Referral"
      }
    ]
  },
  "agent": [
    {
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
            "code": "AUT"
          }
        ]
      },
      "who": {
        "reference": "Practitioner/xcda-author"
      }
    },
    {
      "id": "a1",
      "type": {
        "coding": [
          {
            "system": "http://terminology.hl7.org/CodeSystem/v3-ParticipationType",
            "code": "DEV"
          }
        ]
      },
      "who": {
        "display": "Device/software"
      }
    }
  ],
  "entity": [
    {
      "role": "source",
      "what": {
        "reference": "DocumentReference/example",
        "display": "CDA Document in XDS repository"
      }
    }
  ],
  "meta": {
    "tag": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason",
        "code": "HTEST",
        "display": "test health data"
      }
    ]
  }
}