This is the Continuous Integration Build of FHIR (will be incorrect/inconsistent at times).
See the Directory of published versions
Orders and Observations Work Group | Maturity Level: 4 | Trial Use | Security 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 |
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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 (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 |
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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 (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 |
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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 |
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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 (Preferred) | ||||||||||||
Type | Coding|uri|canonical | ||||||||||||
[x] Note | See Choice of Datatypes for further information about how to use [x] | ||||||||||||
Summary | true |