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 |
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.
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 and as profiled in IHE Mobile Access to Health Documents .
DocumentReference
contains metadata, inline content or direct references to documents such as:
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 , or a DICOM WADO-RS exchange, or an HL7 V2 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.
Structure
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(Any) | Main clinical acts documented Binding: v3 Code System ActCode (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) | 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 |
See the Extensions for this resource
UML Diagram (Legend)
XML Template
<DocumentReference xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier> <version value="[string]"/><!-- 0..1 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 --></basedOn> <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error --> <docStatus value="[code]"/><!-- 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown --> <modality><!-- 0..* CodeableConcept Imaging modality used --></modality> <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type> <category><!-- 0..* CodeableConcept Categorization of document --></category> <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject> <context><!-- I 0..* Reference(Appointment|Encounter|EpisodeOfCare) Encounter the document reference is part of --></context> <event><!-- 0..* CodeableReference(Any) Main clinical acts documented --></event> <related><!-- 0..* Reference(Any) Related identifiers or resources associated with the document reference --></related> <bodySite><!-- 0..* CodeableReference(BodyStructure) Body part included --></bodySite> <facilityType><!-- I 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType> <practiceSetting><!-- I 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting> <period><!-- 0..1 Period Time of service that is being documented --></period> <date value="[dateTime]"/><!-- 0..1 When this document reference was created --> <author><!-- 0..* Reference(CareTeam|Device|Organization|Patient|Practitioner| PractitionerRole|RelatedPerson) Who and/or what authored the document --></author> <attester> <!-- 0..* Attests to accuracy of the document --> <mode><!-- 1..1 CodeableConcept personal | professional | legal | official --></mode> <time value="[dateTime]"/><!-- 0..1 When the document was attested --> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Who attested the document --></party> </attester> <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document --></custodian> <relatesTo> <!-- 0..* Relationships to other documents --> <code><!-- 1..1 CodeableConcept The relationship type with another document --></code> <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target> </relatesTo> <description value="[markdown]"/><!-- 0..1 Human-readable description --> <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel> <content> <!-- 1..* Document referenced --> <attachment><!-- 1..1 Attachment Where to access the document --></attachment> <profile> <!-- 0..* Content profile rules for the document --> <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical --></value[x]> </profile> </content> </DocumentReference>
JSON Template
{ "resourceType" : "DocumentReference", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifiers for the document "version" : "<string>", // An explicitly assigned identifier of a variation of the content in the DocumentReference "basedOn" : [{ 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" : "<code>", // R! current | superseded | entered-in-error "docStatus" : "<code>", // registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown "modality" : [{ CodeableConcept }], // Imaging modality used "type" : { CodeableConcept }, // Kind of document (LOINC if possible) "category" : [{ CodeableConcept }], // Categorization of document "subject" : { Reference(Any) }, // Who/what is the subject of the document "context" : [{ Reference(Appointment|Encounter|EpisodeOfCare) }], // I Encounter the document reference is part of "event" : [{ CodeableReference(Any) }], // Main clinical acts documented "related" : [{ Reference(Any) }], // Related identifiers or resources associated with the document reference "bodySite" : [{ CodeableReference(BodyStructure) }], // Body part included "facilityType" : { CodeableConcept }, // I Kind of facility where patient was seen "practiceSetting" : { CodeableConcept }, // I Additional details about where the content was created (e.g. clinical specialty) "period" : { Period }, // Time of service that is being documented "date" : "<dateTime>", // When this document reference was created "author" : [{ Reference(CareTeam|Device|Organization|Patient|Practitioner| PractitionerRole|RelatedPerson) }], // Who and/or what authored the document "attester" : [{ // Attests to accuracy of the document "mode" : { CodeableConcept }, // R! personal | professional | legal | official "time" : "<dateTime>", // When the document was attested "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Who attested the document }], "custodian" : { Reference(Organization) }, // Organization which maintains the document "relatesTo" : [{ // Relationships to other documents "code" : { CodeableConcept }, // R! The relationship type with another document "target" : { Reference(DocumentReference) } // R! Target of the relationship }], "description" : "<markdown>", // Human-readable description "securityLabel" : [{ CodeableConcept }], // Document security-tags "content" : [{ // R! Document referenced "attachment" : { Attachment }, // R! Where to access the document "profile" : [{ // Content profile rules for the document // value[x]: Code|uri|canonical. One of these 3: "valueCoding" : { Coding }, "valueUri" : "<uri>", "valueCanonical" : "<canonical>" }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:DocumentReference; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business identifiers for the document fhir:version [ string ] ; # 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference fhir:basedOn ( [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract| CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest| ImmunizationRecommendation|MedicationRequest|NutritionOrder| RequestOrchestration|ServiceRequest|SupplyRequest|VisionPrescription) ] ... ) ; # 0..* Procedure that caused this media to be created fhir:status [ code ] ; # 1..1 current | superseded | entered-in-error fhir:docStatus [ code ] ; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown fhir:modality ( [ CodeableConcept ] ... ) ; # 0..* Imaging modality used fhir:type [ CodeableConcept ] ; # 0..1 Kind of document (LOINC if possible) fhir:category ( [ CodeableConcept ] ... ) ; # 0..* Categorization of document fhir:subject [ Reference(Any) ] ; # 0..1 Who/what is the subject of the document fhir:context ( [ Reference(Appointment|Encounter|EpisodeOfCare) ] ... ) ; # 0..* I Encounter the document reference is part of fhir:event ( [ CodeableReference(Any) ] ... ) ; # 0..* Main clinical acts documented fhir:related ( [ Reference(Any) ] ... ) ; # 0..* Related identifiers or resources associated with the document reference fhir:bodySite ( [ CodeableReference(BodyStructure) ] ... ) ; # 0..* Body part included fhir:facilityType [ CodeableConcept ] ; # 0..1 I Kind of facility where patient was seen fhir:practiceSetting [ CodeableConcept ] ; # 0..1 I Additional details about where the content was created (e.g. clinical specialty) fhir:period [ Period ] ; # 0..1 Time of service that is being documented fhir:date [ dateTime ] ; # 0..1 When this document reference was created fhir:author ( [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ... ) ; # 0..* Who and/or what authored the document fhir:attester ( [ # 0..* Attests to accuracy of the document fhir:mode [ CodeableConcept ] ; # 1..1 personal | professional | legal | official fhir:time [ dateTime ] ; # 0..1 When the document was attested fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who attested the document ] ... ) ; fhir:custodian [ Reference(Organization) ] ; # 0..1 Organization which maintains the document fhir:relatesTo ( [ # 0..* Relationships to other documents fhir:code [ CodeableConcept ] ; # 1..1 The relationship type with another document fhir:target [ Reference(DocumentReference) ] ; # 1..1 Target of the relationship ] ... ) ; fhir:description [ markdown ] ; # 0..1 Human-readable description fhir:securityLabel ( [ CodeableConcept ] ... ) ; # 0..* Document security-tags fhir:content ( [ # 1..* Document referenced fhir:attachment [ Attachment ] ; # 1..1 Where to access the document fhir:profile ( [ # 0..* Content profile rules for the document # value[x] : 1..1 Code|uri|canonical. One of these 3 fhir:value [ a fhir:Coding ; Coding ] fhir:value [ a fhir:uri ; uri ] fhir:value [ a fhir:canonical ; canonical ] ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
DocumentReference | |
DocumentReference.version |
|
DocumentReference.basedOn |
|
DocumentReference.docStatus |
|
DocumentReference.modality |
|
DocumentReference.subject |
|
DocumentReference.context |
|
DocumentReference.event |
|
DocumentReference.related |
|
DocumentReference.bodySite |
|
DocumentReference.facilityType |
|
DocumentReference.practiceSetting |
|
DocumentReference.period |
|
DocumentReference.date |
|
DocumentReference.author |
|
DocumentReference.attester |
|
DocumentReference.attester.mode |
|
DocumentReference.attester.time |
|
DocumentReference.attester.party |
|
DocumentReference.relatesTo.code |
|
DocumentReference.description |
|
DocumentReference.securityLabel |
|
DocumentReference.content.profile |
|
DocumentReference.content.profile.value[x] |
|
DocumentReference.masterIdentifier |
|
DocumentReference.authenticator |
|
DocumentReference.content.format |
|
DocumentReference.context.encounter |
|
DocumentReference.context.event |
|
DocumentReference.context.period |
|
DocumentReference.context.facilityType |
|
DocumentReference.context.practiceSetting |
|
DocumentReference.context.sourcePatientInfo |
|
DocumentReference.context.related |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Structure
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(Any) | Main clinical acts documented Binding: v3 Code System ActCode (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) | 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 |
See the Extensions for this resource
XML Template
<DocumentReference xmlns="http://hl7.org/fhir"> <!-- from Resource: id, meta, implicitRules, and language --> <!-- from DomainResource: text, contained, extension, and modifierExtension --> <identifier><!-- 0..* Identifier Business identifiers for the document --></identifier> <version value="[string]"/><!-- 0..1 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 --></basedOn> <status value="[code]"/><!-- 1..1 current | superseded | entered-in-error --> <docStatus value="[code]"/><!-- 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown --> <modality><!-- 0..* CodeableConcept Imaging modality used --></modality> <type><!-- 0..1 CodeableConcept Kind of document (LOINC if possible) --></type> <category><!-- 0..* CodeableConcept Categorization of document --></category> <subject><!-- 0..1 Reference(Any) Who/what is the subject of the document --></subject> <context><!-- I 0..* Reference(Appointment|Encounter|EpisodeOfCare) Encounter the document reference is part of --></context> <event><!-- 0..* CodeableReference(Any) Main clinical acts documented --></event> <related><!-- 0..* Reference(Any) Related identifiers or resources associated with the document reference --></related> <bodySite><!-- 0..* CodeableReference(BodyStructure) Body part included --></bodySite> <facilityType><!-- I 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType> <practiceSetting><!-- I 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) --></practiceSetting> <period><!-- 0..1 Period Time of service that is being documented --></period> <date value="[dateTime]"/><!-- 0..1 When this document reference was created --> <author><!-- 0..* Reference(CareTeam|Device|Organization|Patient|Practitioner| PractitionerRole|RelatedPerson) Who and/or what authored the document --></author> <attester> <!-- 0..* Attests to accuracy of the document --> <mode><!-- 1..1 CodeableConcept personal | professional | legal | official --></mode> <time value="[dateTime]"/><!-- 0..1 When the document was attested --> <party><!-- 0..1 Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) Who attested the document --></party> </attester> <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document --></custodian> <relatesTo> <!-- 0..* Relationships to other documents --> <code><!-- 1..1 CodeableConcept The relationship type with another document --></code> <target><!-- 1..1 Reference(DocumentReference) Target of the relationship --></target> </relatesTo> <description value="[markdown]"/><!-- 0..1 Human-readable description --> <securityLabel><!-- 0..* CodeableConcept Document security-tags --></securityLabel> <content> <!-- 1..* Document referenced --> <attachment><!-- 1..1 Attachment Where to access the document --></attachment> <profile> <!-- 0..* Content profile rules for the document --> <value[x]><!-- 1..1 Coding|uri|canonical Code|uri|canonical --></value[x]> </profile> </content> </DocumentReference>
JSON Template
{ "resourceType" : "DocumentReference", // from Resource: id, meta, implicitRules, and language // from DomainResource: text, contained, extension, and modifierExtension "identifier" : [{ Identifier }], // Business identifiers for the document "version" : "<string>", // An explicitly assigned identifier of a variation of the content in the DocumentReference "basedOn" : [{ 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" : "<code>", // R! current | superseded | entered-in-error "docStatus" : "<code>", // registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown "modality" : [{ CodeableConcept }], // Imaging modality used "type" : { CodeableConcept }, // Kind of document (LOINC if possible) "category" : [{ CodeableConcept }], // Categorization of document "subject" : { Reference(Any) }, // Who/what is the subject of the document "context" : [{ Reference(Appointment|Encounter|EpisodeOfCare) }], // I Encounter the document reference is part of "event" : [{ CodeableReference(Any) }], // Main clinical acts documented "related" : [{ Reference(Any) }], // Related identifiers or resources associated with the document reference "bodySite" : [{ CodeableReference(BodyStructure) }], // Body part included "facilityType" : { CodeableConcept }, // I Kind of facility where patient was seen "practiceSetting" : { CodeableConcept }, // I Additional details about where the content was created (e.g. clinical specialty) "period" : { Period }, // Time of service that is being documented "date" : "<dateTime>", // When this document reference was created "author" : [{ Reference(CareTeam|Device|Organization|Patient|Practitioner| PractitionerRole|RelatedPerson) }], // Who and/or what authored the document "attester" : [{ // Attests to accuracy of the document "mode" : { CodeableConcept }, // R! personal | professional | legal | official "time" : "<dateTime>", // When the document was attested "party" : { Reference(Organization|Patient|Practitioner|PractitionerRole| RelatedPerson) } // Who attested the document }], "custodian" : { Reference(Organization) }, // Organization which maintains the document "relatesTo" : [{ // Relationships to other documents "code" : { CodeableConcept }, // R! The relationship type with another document "target" : { Reference(DocumentReference) } // R! Target of the relationship }], "description" : "<markdown>", // Human-readable description "securityLabel" : [{ CodeableConcept }], // Document security-tags "content" : [{ // R! Document referenced "attachment" : { Attachment }, // R! Where to access the document "profile" : [{ // Content profile rules for the document // value[x]: Code|uri|canonical. One of these 3: "valueCoding" : { Coding }, "valueUri" : "<uri>", "valueCanonical" : "<canonical>" }] }] }
Turtle Template
@prefix fhir: <http://hl7.org/fhir/> . [ a fhir:DocumentReference; fhir:nodeRole fhir:treeRoot; # if this is the parser root # from Resource: .id, .meta, .implicitRules, and .language # from DomainResource: .text, .contained, .extension, and .modifierExtension fhir:identifier ( [ Identifier ] ... ) ; # 0..* Business identifiers for the document fhir:version [ string ] ; # 0..1 An explicitly assigned identifier of a variation of the content in the DocumentReference fhir:basedOn ( [ Reference(Appointment|AppointmentResponse|CarePlan|Claim|CommunicationRequest|Contract| CoverageEligibilityRequest|DeviceRequest|EnrollmentRequest| ImmunizationRecommendation|MedicationRequest|NutritionOrder| RequestOrchestration|ServiceRequest|SupplyRequest|VisionPrescription) ] ... ) ; # 0..* Procedure that caused this media to be created fhir:status [ code ] ; # 1..1 current | superseded | entered-in-error fhir:docStatus [ code ] ; # 0..1 registered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown fhir:modality ( [ CodeableConcept ] ... ) ; # 0..* Imaging modality used fhir:type [ CodeableConcept ] ; # 0..1 Kind of document (LOINC if possible) fhir:category ( [ CodeableConcept ] ... ) ; # 0..* Categorization of document fhir:subject [ Reference(Any) ] ; # 0..1 Who/what is the subject of the document fhir:context ( [ Reference(Appointment|Encounter|EpisodeOfCare) ] ... ) ; # 0..* I Encounter the document reference is part of fhir:event ( [ CodeableReference(Any) ] ... ) ; # 0..* Main clinical acts documented fhir:related ( [ Reference(Any) ] ... ) ; # 0..* Related identifiers or resources associated with the document reference fhir:bodySite ( [ CodeableReference(BodyStructure) ] ... ) ; # 0..* Body part included fhir:facilityType [ CodeableConcept ] ; # 0..1 I Kind of facility where patient was seen fhir:practiceSetting [ CodeableConcept ] ; # 0..1 I Additional details about where the content was created (e.g. clinical specialty) fhir:period [ Period ] ; # 0..1 Time of service that is being documented fhir:date [ dateTime ] ; # 0..1 When this document reference was created fhir:author ( [ Reference(CareTeam|Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ... ) ; # 0..* Who and/or what authored the document fhir:attester ( [ # 0..* Attests to accuracy of the document fhir:mode [ CodeableConcept ] ; # 1..1 personal | professional | legal | official fhir:time [ dateTime ] ; # 0..1 When the document was attested fhir:party [ Reference(Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ] ; # 0..1 Who attested the document ] ... ) ; fhir:custodian [ Reference(Organization) ] ; # 0..1 Organization which maintains the document fhir:relatesTo ( [ # 0..* Relationships to other documents fhir:code [ CodeableConcept ] ; # 1..1 The relationship type with another document fhir:target [ Reference(DocumentReference) ] ; # 1..1 Target of the relationship ] ... ) ; fhir:description [ markdown ] ; # 0..1 Human-readable description fhir:securityLabel ( [ CodeableConcept ] ... ) ; # 0..* Document security-tags fhir:content ( [ # 1..* Document referenced fhir:attachment [ Attachment ] ; # 1..1 Where to access the document fhir:profile ( [ # 0..* Content profile rules for the document # value[x] : 1..1 Code|uri|canonical. One of these 3 fhir:value [ a fhir:Coding ; Coding ] fhir:value [ a fhir:uri ; uri ] fhir:value [ a fhir:canonical ; canonical ] ] ... ) ; ] ... ) ; ]
Changes from both R4 and R4B
DocumentReference | |
DocumentReference.version |
|
DocumentReference.basedOn |
|
DocumentReference.docStatus |
|
DocumentReference.modality |
|
DocumentReference.subject |
|
DocumentReference.context |
|
DocumentReference.event |
|
DocumentReference.related |
|
DocumentReference.bodySite |
|
DocumentReference.facilityType |
|
DocumentReference.practiceSetting |
|
DocumentReference.period |
|
DocumentReference.date |
|
DocumentReference.author |
|
DocumentReference.attester |
|
DocumentReference.attester.mode |
|
DocumentReference.attester.time |
|
DocumentReference.attester.party |
|
DocumentReference.relatesTo.code |
|
DocumentReference.description |
|
DocumentReference.securityLabel |
|
DocumentReference.content.profile |
|
DocumentReference.content.profile.value[x] |
|
DocumentReference.masterIdentifier |
|
DocumentReference.authenticator |
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DocumentReference.content.format |
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DocumentReference.context.encounter |
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DocumentReference.context.event |
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DocumentReference.context.period |
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DocumentReference.context.facilityType |
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DocumentReference.context.practiceSetting |
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DocumentReference.context.sourcePatientInfo |
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DocumentReference.context.related |
|
See the Full Difference for further information
This analysis is available for R4 as XML or JSON and for R4B as XML or JSON.
Additional definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions, the spreadsheet version & the dependency analysis
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 | 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 | 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 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 | 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. |
UniqueKey | Level | Location | Description | Expression |
docRef-1 | Warning | (base) | facilityType SHALL only be present if context is not an encounter | facilityType.empty() or context.where(resolve() is Encounter).empty() |
docRef-2 | Warning | (base) | practiceSetting SHALL only be present if context is not present | practiceSetting.empty() or context.where(resolve() is Encounter).empty() |
DocumentReference.content.attachment.data
, and DocumentReference.content.attachment.url
.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. 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, Organization, Patient, PractitionerRole, RelatedPerson) |
|
author | reference | Who and/or what authored the document | DocumentReference.author (Practitioner, 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: code relation: target |
|
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 |