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Orders and Observations icon Work GroupMaturity Level: 4 Trial UseSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Detailed Descriptions for the elements in the DocumentReference resource.

DocumentReference
Element Id DocumentReference
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.

Short Display A reference to a document
Cardinality 0..*
Type DomainResource
Summary false
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 Id DocumentReference.identifier
Definition

Business identifiers assigned to this document reference by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server.

Short Display Business identifiers for the document
Note This is a business identifier, not a resource identifier (see discussion)
Cardinality 0..*
Type Identifier
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.

Summary true
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.version
Element Id DocumentReference.version
Definition

An explicitly assigned identifier of a variation of the content in the DocumentReference.

Short Display An explicitly assigned identifier of a variation of the content in the DocumentReference
Note This is a business versionId, not a resource version id (see discussion)
Cardinality 0..1
Type string
Summary true
Comments

While each resource, including the DocumentReference itself, has its own version identifier, this is a formal identifier for the logical version of the DocumentReference as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

DocumentReference.basedOn
Element Id DocumentReference.basedOn
Definition

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

Short Display Procedure that caused this media to be created
Cardinality 0..*
Type Reference(Appointment | AppointmentResponse | CarePlan | Claim | CommunicationRequest | Contract | CoverageEligibilityRequest | DeviceRequest | EnrollmentRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | RequestOrchestration | ServiceRequest | SupplyRequest | VisionPrescription)
Requirements

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

Alternate Names fulfills
Summary false
DocumentReference.status
Element Id DocumentReference.status
Definition

The current state of the document reference.

Short Display current | superseded | entered-in-error
Cardinality 1..1
Terminology Binding DocumentReferenceStatus (Required)
Type code
Is Modifier true (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)
Summary true
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 Id DocumentReference.docStatus
Definition

The status of the underlying document.

Short Display registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown
Cardinality 0..1
Terminology Binding Composition Status (Required)
Type code
Is Modifier true (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)
Summary true
Comments

The document that is pointed to might be in various lifecycle states.

DocumentReference.modality
Element Id DocumentReference.modality
Definition

Imaging modality used. This may include both acquisition and non-acquisition modalities.

Short Display Imaging modality used
Cardinality 0..*
Terminology Binding Modality icon (Extensible)
Type CodeableConcept
Summary true
DocumentReference.type
Element Id DocumentReference.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.

Short Display Kind of document (LOINC if possible)
Cardinality 0..1
Terminology Binding FHIR Document Type Codes (Preferred)
Type CodeableConcept
Summary true
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 Id DocumentReference.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.

Short Display Categorization of document
Cardinality 0..*
Terminology Binding Referenced Item Category Value Set (Example)
Type CodeableConcept
Alternate Names class; classCode
Summary true
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 Id DocumentReference.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).

Short Display Who/what is the subject of the document
Cardinality 0..1
Type Reference(Any)
Summary true
DocumentReference.context
Element Id DocumentReference.context
Definition

The Encounter during which this document reference was created or to which the creation of this record is tightly associated.

Short Display Encounter the document reference is part of
Cardinality 0..*
Type Reference(Appointment | Encounter | EpisodeOfCare)
Requirements

Links the document reference to the Encounter context. May also affect access control.

Summary true
Comments

This will typically be the encounter the document reference was created during, but some document references may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission lab tests).

Invariants
Affect 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.event
Element Id DocumentReference.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.

Short Display Main clinical acts documented
Cardinality 0..*
Terminology Binding v3 Code System ActCode icon (Example)
Type CodeableReference(Any)
Summary false
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.related
Element Id DocumentReference.related
Definition

Any other resource this document reference was created or to which the creation of this record is tightly associated.

Short Display Related identifiers or resources associated with the document reference
Cardinality 0..*
Type Reference(Any)
Summary false
Comments

Use only for references not covered by other elements.

DocumentReference.bodySite
Element Id DocumentReference.bodySite
Definition

The anatomic structures included in the document.

Short Display Body part included
Cardinality 0..*
Terminology Binding SNOMED CT Body Structures (Example)
Type CodeableReference(BodyStructure)
Summary true
DocumentReference.facilityType
Element Id DocumentReference.facilityType
Definition

The kind of facility where the patient was seen.

Short Display Kind of facility where patient was seen
Cardinality 0..1
Terminology Binding Facility Type Code Value Set (Example)
Type CodeableConcept
Summary false
Invariants
Affect this element
docRef-1Warning facilityType SHALL only be present if context is not an encounterfacilityType.empty() or context.where(resolve() is Encounter).empty()
DocumentReference.practiceSetting
Element Id DocumentReference.practiceSetting
Definition

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

Short Display Additional details about where the content was created (e.g. clinical specialty)
Cardinality 0..1
Terminology Binding Practice Setting Code Value Set (Example)
Type CodeableConcept
Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Summary false
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.

Invariants
Affect this element
docRef-2Warning practiceSetting SHALL only be present if context is not presentpracticeSetting.empty() or context.where(resolve() is Encounter).empty()
DocumentReference.period
Element Id DocumentReference.period
Definition

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

Short Display Time of service that is being documented
Cardinality 0..1
Type Period
Summary true
DocumentReference.date
Element Id DocumentReference.date
Definition

When the document reference was created.

Short Display When this document reference was created
Cardinality 0..1
Type dateTime
Alternate Names indexed
Summary true
Comments

Referencing/indexing time is used for tracking, organizing versions and searching. Provide the most precise timestamp available.

DocumentReference.author
Element Id DocumentReference.author
Definition

Identifies who is responsible for adding the information to the document.

Short Display Who and/or what authored the document
Cardinality 0..*
Type Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam)
Summary true
Comments

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

DocumentReference.attester
Element Id DocumentReference.attester
Definition

A participant who has authenticated the accuracy of the document.

Short Display Attests to accuracy of the document
Cardinality 0..*
Requirements

Identifies responsibility for the accuracy of the document content.

Summary false
Comments

Only list each attester once.

DocumentReference.attester.mode
Element Id DocumentReference.attester.mode
Definition

The type of attestation the authenticator offers.

Short Display personal | professional | legal | official
Cardinality 1..1
Terminology Binding Composition Attestation Mode (Preferred)
Type CodeableConcept
Requirements

Indicates the level of authority of the attestation.

Summary false
DocumentReference.attester.time
Element Id DocumentReference.attester.time
Definition

When the document was attested by the party.

Short Display When the document was attested
Cardinality 0..1
Type dateTime
Requirements

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

Summary false
DocumentReference.attester.party
Element Id DocumentReference.attester.party
Definition

Who attested the document in the specified way.

Short Display Who attested the document
Cardinality 0..1
Type Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)
Requirements

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

Summary false
DocumentReference.custodian
Element Id DocumentReference.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Short Display Organization which maintains the document
Cardinality 0..1
Type Reference(Organization)
Summary false
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 Id DocumentReference.relatesTo
Definition

Relationships that this document has with other document references that already exist.

Short Display Relationships to other documents
Cardinality 0..*
Summary true
Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

DocumentReference.relatesTo.code
Element Id DocumentReference.relatesTo.code
Definition

The type of relationship that this document has with anther document.

Short Display The relationship type with another document
Cardinality 1..1
Terminology Binding Document Relationship Type (Extensible)
Type CodeableConcept
Summary true
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

DocumentReference.relatesTo.target
Element Id DocumentReference.relatesTo.target
Definition

The target document of this relationship.

Short Display Target of the relationship
Cardinality 1..1
Type Reference(DocumentReference)
Summary true
DocumentReference.description
Element Id DocumentReference.description
Definition

Human-readable description of the source document.

Short Display Human-readable description
Cardinality 0..1
Type markdown
Requirements

Helps humans to assess whether the document is of interest.

Summary true
Comments

What the document is about, a terse summary of the document.

DocumentReference.securityLabel
Element Id DocumentReference.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.

Short Display Document security-tags
Cardinality 0..*
Terminology Binding Example set of Security Labels (Example)
Type CodeableConcept
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Summary true
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 Id DocumentReference.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.

Short Display Document referenced
Cardinality 1..*
Requirements

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

Summary true
Comments

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

DocumentReference.content.attachment
Element Id DocumentReference.content.attachment
Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Short Display Where to access the document
Cardinality 1..1
Type Attachment
Summary true
DocumentReference.content.profile
Element Id DocumentReference.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.

Short Display Content profile rules for the document
Cardinality 0..*
Alternate Names format; formatCode
Summary true
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 Id DocumentReference.content.profile.value[x]
Definition

Code|uri|canonical.

Short Display Code|uri|canonical
Cardinality 1..1
Terminology Binding HL7 ValueSet of Format Codes for use with Document Sharing icon (Preferred)
Type Coding|uri|canonical
[x] Note See Choice of Datatypes for further information about how to use [x]
Summary true