US Core Implementation Guide
7.0.0 - STU7 United States of America flag

US Core Implementation Guide, published by HL7 International / Cross-Group Projects. This guide is not an authorized publication; it is the continuous build for version 7.0.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/HL7/US-Core/ and changes regularly. See the Directory of published versions

Resource Profile: US Core DocumentReference Profile

Official URL: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference Version: 7.0.0
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreDocumentReferenceProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.20

Copyright/Legal: Used by permission of HL7 International, all rights reserved Creative Commons License

The US Core DocumentReference Profile inherits from the FHIR DocumentReference resource; refer to it for scope and usage definitions. This profile sets minimum expectations for searching and fetching patient documents including Clinical Notes using the DocumentReference resource. It specifies which core elements, extensions, vocabularies, and value sets SHALL be present and constrains how the elements are used. Providing the floor for standards development for specific use cases promotes interoperability and adoption. Before reviewing this profile, implementers are encouraged to read the Clinical Notes Guidance to understand the overlap of the US Core DiagnosticReport Profile for Report and Note exchange and the US Core DocumentReference Profile.

Example Usage Scenarios:

The following are example usage scenarios for the US Core DocumentReference profile. See the Clinical Notes section for additional details on using this profile for Clinical Notes:

  • Query for all documents belonging to a Patient
  • Query for a specific Clinical Note type (e.g., Discharge Summary or Continuity of Care Document (CCD))
  • Query for all Clinical Notes belonging to a Patient
  • Write a new Note to a Patient’s Chart

Mandatory and Must Support Data Elements

The following data elements must always be present (Mandatory definition) or must be supported if the data is present in the sending system (Must Support definition). They are presented below in a simple human-readable explanation. Profile specific guidance and examples are provided as well. The Formal Views below provides the formal summary, definitions, and terminology requirements.

Each DocumentReference Must Have:

  1. a status
  2. a code describing the type of document
  3. a document category
  4. a patient
  5. document referenced (content)
  6. the MIME type (i.e., contentType) of the document

Each DocumentReference Must Support:

  1. a business identifier for the DocumentReference (possibly generated by the transcription system or EHR)
  2. date and time the reference was created
  3. an author
  4. a code identifying the specific details about the format of the document — over and above the content’s MIME type
  5. the patient encounter that is being referenced
  6. clinically relevant date

Additional USCDI Requirements:

This Additional USCDI Requirements element is not Mandatory or Must Support but is required for ONC Health IT certification testing and is included in the formal definition of the profile and the DocumentReference examples.

  1. a document category limited to The US Core DocumentReferences Type Value Set, which currently consists of a single value, “clinical note.”

Profile Specific Implementation Guidance:

  • See Clinical Notes
  • The DocumentReference.type binding Must Support, at a minimum, the 5 Common Clinical Notes and may extend to the whole US Core DocumentReference Type Value Set
  • In addition to the US Core DocumentReference Category value set, other category schemes such as the LOINC-based Document Class Value Set and IHE XDSclassCode may be used to facilitate the sharing of health documents.
  • For a C-CDA Clinical Summary of Care (CCD):
    • The document type code is the LOINC code 34133-9 Summary of episode note.
    • The format code is urn:hl7-org:sdwg:ccda-structuredBody:2.1
  • The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.attachment.url or the content as inline base64 encoded data using DocumentReference.attachment.data.
    • Although both are marked as Must Support, the server system is not required to support an address and inline base64 encoded data, but SHALL support at least one of these elements.
    • The client application SHALL support both elements.
    • The content.url may refer to a FHIR Binary Resource (i.e., [base]/Binary/[id]), FHIR Document Bundle (i.e., [base]/Bundle/[id], or another endpoint.
      • If the endpoint is outside the FHIR base URL, it SHOULD NOT require additional authorization to access.
    • If there are multiple DocumentReference.content element repetitions, these SHALL all represent the same document in different formats or attachment metadata. The content element SHALL NOT contain different versions of the same content. For version handling, use multiple DocumentReferences with DocumentReference.relatesTo.
  • Every DocumentReference must have a responsible Organization. The organization responsible for the DocumentReference SHALL be present either in DocumentReference.custodian or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who or Provenance.agent.onBehalfOf.
    • Some systems may also expose the same organization in referenced Encounter in Encounter.serviceProvider.

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 0..* Identifier Other identifiers for the document
... status S 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category S 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
.... category:uscore 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

... subject S 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
... date S 0..1 instant When this document reference was created
... author S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) Who and/or what authored the document
... content S 1..* BackboneElement Document referenced
.... attachment SC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S 0..1 code Mime type of the content, with charset etc.
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SC 0..1 url Uri where the data can be found
.... format S 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context S 0..1 BackboneElement Clinical context of document
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period S 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile) Who and/or what authored the document
... content SΣ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()
NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) Who and/or what authored the document
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
... custodian 0..1 Reference(Organization) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title Σ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... identifier S 0..* Identifier Other identifiers for the document
... status S 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type S 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category S 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
.... category:uscore 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets

... subject S 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
... date S 0..1 instant When this document reference was created
... author S 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) Who and/or what authored the document
... content S 1..* BackboneElement Document referenced
.... attachment SC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType S 0..1 code Mime type of the content, with charset etc.
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SC 0..1 url Uri where the data can be found
.... format S 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context S 0..1 BackboneElement Clinical context of document
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period S 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile) Who and/or what authored the document
... content SΣ 1..* BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... period SΣ 0..1 Period Time of service that is being documented

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... language 0..1 code Language of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding
... text 0..1 Narrative Text summary of the resource, for human interpretation
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
... identifier SΣ 0..* Identifier Other identifiers for the document
... status ?!SΣ 1..1 code current | superseded | entered-in-error
Binding: DocumentReferenceStatus (required)
... docStatus Σ 0..1 code preliminary | final | amended | entered-in-error
Binding: CompositionStatus (required): Status of the underlying document.

... type SΣ 1..1 CodeableConcept Kind of document (LOINC if possible)
Binding: US Core DocumentReference Type (required): All LOINC values whose SCALE is "Doc" in the LOINC database and the HL7 v3 Code System NullFlavor concept 'unknown'

Additional BindingsPurpose
US Core Clinical Note Type Min Binding
... Slices for category SΣ 1..* CodeableConcept Categorization of document
Slice: Unordered, Open by pattern:$this
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


.... category:uscore Σ 0..* CodeableConcept 𝗔𝗗𝗗𝗜𝗧𝗜𝗢𝗡𝗔𝗟 𝗨𝗦𝗖𝗗𝗜: Categorization of document
Binding: US Core DocumentReference Category (required): The US Core DocumentReferences Type Value Set is a "starter set" of categories supported for fetching and storing clinical notes. Note that other codes are permitted, see Required Bindings When Slicing by Value Sets


... subject SΣ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
... date SΣ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(US Core Practitioner Profile S | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | Device) Who and/or what authored the document
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
... custodian 0..1 Reference(Organization) Organization which maintains the document
... relatesTo Σ 0..* BackboneElement Relationships to other documents
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.

.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel Σ 0..* CodeableConcept Document security-tags
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.


... content SΣ 1..* BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 0..1 code Mime type of the content, with charset etc.
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.


Example General: text/plain; charset=UTF-8, image/png
..... language Σ 0..1 code Human language of the content (BCP-47)
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data SC 0..1 base64Binary Data inline, base64ed
..... url SΣC 0..1 url Uri where the data can be found
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title Σ 0..1 string Label to display in place of the data
Example General: Official Corporate Logo
..... creation Σ 0..1 dateTime Date attachment was first created
.... format SΣ 0..1 Coding Format/content rules for the document
Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
... context SΣ 0..1 BackboneElement Clinical context of document
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.


.... period SΣ 0..1 Period Time of service that is being documented
.... facilityType 0..1 CodeableConcept Kind of facility where patient was seen
Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.

.... practiceSetting 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).

.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

PathConformanceValueSetURI
DocumentReference.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.statusrequiredDocumentReferenceStatus
http://hl7.org/fhir/ValueSet/document-reference-status
from the FHIR Standard
DocumentReference.docStatusrequiredCompositionStatus
http://hl7.org/fhir/ValueSet/composition-status|4.0.1
from the FHIR Standard
DocumentReference.typerequiredUSCoreDocumentReferenceType
Additional Bindings Purpose
US Core Clinical Note Type Min Binding
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
from this IG
DocumentReference.categoryexampleDocumentClassValueSet
http://hl7.org/fhir/ValueSet/document-classcodes
from the FHIR Standard
DocumentReference.category:uscorerequiredUSCoreDocumentReferenceCategory (a valid code from US Core DocumentReferences Category Codes)
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-category
from this IG
DocumentReference.relatesTo.coderequiredDocumentRelationshipType
http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1
from the FHIR Standard
DocumentReference.securityLabelextensibleAll Security Labels
http://hl7.org/fhir/ValueSet/security-labels
from the FHIR Standard
DocumentReference.content.attachment.contentTyperequiredMime Types (a valid code from urn:ietf:bcp:13)
http://hl7.org/fhir/ValueSet/mimetypes|4.0.1
from the FHIR Standard
DocumentReference.content.attachment.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
http://hl7.org/fhir/ValueSet/languages
from the FHIR Standard
DocumentReference.content.formatextensibleHL7FormatCodes
http://terminology.hl7.org/ValueSet/v3-HL7FormatCodes
DocumentReference.context.eventexampleActCode
http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.facilityTypeexampleFacilityTypeCodeValueSet
http://hl7.org/fhir/ValueSet/c80-facilitycodes
from the FHIR Standard
DocumentReference.context.practiceSettingexamplePracticeSettingCodeValueSet
http://hl7.org/fhir/ValueSet/c80-practice-codes
from the FHIR Standard

Constraints

IdGradePath(s)DetailsRequirements
us-core-6errorDocumentReference.content.attachmentDocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
: url.exists() or data.exists()

 

Other representations of profile: CSV, Excel, Schematron

Notes:

Quick Start

Below is an overview of the required Server RESTful FHIR interactions for this profile - for example, search and read operations - when supporting the US Core interactions to access this profile’s information (Profile Support + Interaction Support). Note that systems that support only US Core Profiles (Profile Only Support) are not required to support these interactions. See the US Core Server CapabilityStatement for a complete list of supported RESTful interactions for this IG.

  • See the Scopes Format section for a description of the SMART scopes syntax.
  • See the Search Syntax section for a description of the US Core search syntax.
  • See the General Requirements section for additional rules and expectations when a server requires status parameters.
  • See the General Guidance section for additional guidance on searching for multiple patients.

US Core Scopes

Servers providing access to clniical note data SHALL support these US Core SMART Scopes:

Servers providing access to clniical note data SHOULD support these US Core SMART Scopes:

  • granular scopes: <patient|user|system>.DocumentReference.rs?category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

Mandatory Search Parameters:

The following search parameters and search parameter combinations SHALL be supported:

  1. SHALL support both read DocumentReference by id AND DocumentReference search using the _id search parameter:

    GET [base]/DocumentReference/[id] or GET [base]/DocumentReference?_id=[id]

    Example:

    1. GET [base]/DocumentReference/2169591
    2. GET [base]/DocumentReference?_id=2169591

    Implementation Notes: Fetches a single DocumentReference. The document itself is represented as a base64 encoded binary data element or retrieved using the link provided by the resource. If the document is a relative link to a [Binary] resource like a resource reference, it can be subsequently retrieved using: GET [base]/Binary/[id]. (how to search by the logical id of the resource)

  2. SHALL support searching for all documentreferences for a patient using the patient search parameter:

    GET [base]/DocumentReference?patient={Type/}[id]

    Example:

    1. GET [base]/DocumentReference?patient=1137192

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient. See the implementation notes above for how to access the actual document. (how to search by reference)

  3. SHALL support searching using the combination of the patient and category search parameters:

    GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

    Example:

    1. GET [base]/DocumentReference?patient=1235541&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical-note. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

  4. SHALL support searching using the combination of the patient and category and date search parameters:
    • including support for these date comparators: gt,lt,ge,le
    • including optional support for AND search on date (e.g.date=[date]&date=[date]]&...)

    GET [base]/DocumentReference?patient={Type/}[id]&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date={gt|lt|ge|le}[date]{&date={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/DocumentReference?patient=1235541&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note&date=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and category = clinical=note and date. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)

  5. SHALL support searching using the combination of the patient and type search parameters:

    GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]

    Example:

    1. GET [base]/DocumentReference?patient=1316024&type=http://loinc.org|18842-5

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

Optional Search Parameters:

The following search parameter combinations SHOULD be supported:

  1. SHOULD support searching using the combination of the patient and status search parameters:
    • including support for OR search on status (e.g.status={system|}[code],{system|}[code],...)

    GET [base]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}

    Example:

    1. GET [base]/DocumentReference?patient=1235541

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and status. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token)

  2. SHOULD support searching using the combination of the patient and type and period search parameters:
    • including support for these period comparators: gt,lt,ge,le
    • including optional support for AND search on period (e.g.period=[date]&period=[date]]&...)

    GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]&period={gt|lt|ge|le}[date]{&period={gt|lt|ge|le}[date]&...}

    Example:

    1. GET [base]/DocumentReference?patient=2169591&type=http://loinc.org |34133-9&period=ge2020-01-01T00:00:00Z

    Implementation Notes: Fetches a bundle of all DocumentReference resources for the specified patient and type and period. See the implementation notes above for how to access the actual document. (how to search by reference and how to search by token and how to search by date)

Mandatory Write Capability:

  1. SHALL support writing a new note to a Patient’s Chart:

    POST [base]/DocumentReference

An example to demonstrate writing a note to the server.

Clinical Note


{
  "resourceType" : "DocumentReference",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference|7.0.0"]
  },
  "status" : "current",
  "type" : {
    "coding" : [{
      "system" : "http://loinc.org",
      "code" : "18842-5",
      "display" : "Discharge Summary"
    }],
    "text" : "Discharge Summary"
  },
  "category" : [{
    "coding" : [{
      "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
      "code" : "clinical-note",
      "display" : "Clinical Note"
    }],
    "text" : "Clinical No"
  }],
  "subject" : {
    "reference" : "Patient/example"
  },
  "content" : [{
    "attachment" : {
      "contentType" : "text/plain",
      "data" : "Tm8gYWN0aXZpdHkgcmVzdHJpY3Rpb24sIHJlZ3VsYXIgZGlldCwgZm9sbG93IHVwIGluIHR3byB0byB0aHJlZSB3ZWVrcyB3aXRoIHByaW1hcnkgY2FyZSBwcm92aWRlci4="
    }
  }],
  "context" : {
    "encounter" : [{
      "reference" : "Encounter/example-1"
    }]
  }
}

Note Content

The content is Base64 encoded and states: “No activity restriction, regular diet, follow up in two to three weeks with primary care provider.”


Mandatory Operation:

  1. SHALL support fetching documents using the $docref operation.

    This $docref operation is used to request a server generate a document based on the specified parameters. This operation is invoked on a FHIR Server’s DocumentReference endpoint (e.g., [base]/DocumentReference/$docref) and operates across all DocumentReference instances returning a Bundle of DocumentReference resources. See the $docref operation definition for detailed documentation.

    • The operation can be invoked using the GET Syntax if the complex type parameter is omitted:

      GET [base]/DocumentReference/$docref?{parameters}

    • Otherwise the POST transaction with used as follows:

      POST [base]/DocumentReference/$docref

      The body of the POST contains the Parameters resource with the $docref operation input parameters.

Example 1: Request the latest CCD

Request the latest CCD for a patient using GET syntax

GET [base]/DocumentReference/$docref?patient=123

Request the latest CCD for a patient using POST syntax

POST [base]/DocumentReference/$docref}

POST request body:

    {
      "resourceType": "Parameters",
      "id": "get-ccd123",
      "parameter": [
        {
          "name": "patient",
          "valueId" : "123"
        }
      ]
    }

Response

HTTP/1.1 200 OK
[other headers]

Response body


{
  "resourceType" : "Bundle",
  "id" : "docref-example-1",
  "type" : "searchset",
  "total" : 1,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/DocumentReference/$docref?patient=123"
  }],
  "entry" : [{
    "fullUrl" : "http://example.org/DocumentReference/ccd123",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "ccd123",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "identifier" : [{
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:2.16.840.1.113883.19.5.99999.1"
      }],
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "34133-9",
          "display" : "Summary of episode note"
        }],
        "text" : "CCD Document"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2016-03-09T15:29:46Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Pulmonology clinic acute visit",
      "content" : [{
        "attachment" : {
          "contentType" : "text/plain",
          "url" : "Binary/1-note",
          "title" : "Uri where the data can be found: http://example.org/Binary/1-note"
        },
        "format" : {
          "system" : "http://terminology.hl7.org/CodeSystem/v3-HL7DocumentFormatCodes",
          "code" : "urn:hl7-org:sdwg:ccda-structuredBody:2.1",
          "display" : "ccda-structuredBody:2.1"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2004-12-23T08:00:00+11:00",
          "end" : "2004-12-23T08:01:00+11:00"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  }]
}


Example 2: Request Procedure Notes and Discharge Summaries for 2019

Request Procedure Notes and Discharge Summaries for 2019 using POST syntax

POST [base]/DocumentReference/$docref}

POST request body:

{
    "resourceType": "Parameters",
    "id": "get-docs",
    "parameter": [
        {
            "name": "patient",
            "valueId": "123"
        },
        {
            "name": "start",
            "valueDateTime": "2019-01-01"
        },
        {
            "name": "end",
            "valueDateTime": "2019-12-31"
        },
        {
            "name": "type",
            "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/c80-doc-typecodes",
                "code": "18842-5",
                "display": "Discharge summary"
            }
        },
        {
            "name": "type",
            "valueCoding": {
                "system": "http://terminology.hl7.org/CodeSystem/c80-doc-typecodes",
                "code": "28570-0",
                "display": "Procedures Note"
            }
        },
        {
            "name": "on-demand",
            "valueBoolean": true
        }
    ]
}

Response

HTTP/1.1 200 OK
[other headers]

Response body


{
  "resourceType" : "Bundle",
  "id" : "docref-example-2",
  "type" : "searchset",
  "total" : 3,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/DocumentReference/$docref?patient=123&start=2019-01-01&end=2019-01-01&type=http://terminology.hl7.org/CodeSystem/c80-doc-typecodes|18842-5,http://terminology.hl7.org/CodeSystem/c80-doc-typecodes|28570-0&ondemand=true"
  }],
  "entry" : [{
    "fullUrl" : "http://example.org/DocumentReference/procedure-note123",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "procedure-note123",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "identifier" : [{
        "system" : "urn:ietf:rfc:3986",
        "value" : "urn:oid:2.16.840.1.113883.19.5.99999.1"
      }],
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "28570-0",
          "display" : "Procedure Note"
        }],
        "text" : "Procedure Note"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/procedure-note123.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-02"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/DocumentReference/procedure-note456",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "procedure-note456",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "28570-0",
          "display" : "Procedure Note"
        }],
        "text" : "Procedure Note"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/procedure-note456.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-06-01",
          "end" : "2019-06-01"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/DocumentReference/discharge",
    "resource" : {
      "resourceType" : "DocumentReference",
      "id" : "discharge",
      "meta" : {
        "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference"]
      },
      "status" : "current",
      "type" : {
        "coding" : [{
          "system" : "http://loinc.org",
          "code" : "18842-5",
          "display" : "Discharge Summary"
        }],
        "text" : "Discharge Summary"
      },
      "category" : [{
        "coding" : [{
          "system" : "http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category",
          "code" : "clinical-note",
          "display" : "Clinical Note"
        }],
        "text" : "Clinical Note"
      }],
      "subject" : {
        "reference" : "Patient/example",
        "display" : "Amy Shaw"
      },
      "date" : "2022-11-18T20:45:05Z",
      "author" : [{
        "reference" : "Practitioner/practitioner-1",
        "display" : "Ronald Bone, MD"
      }],
      "description" : "Ureteroscopy",
      "content" : [{
        "attachment" : {
          "contentType" : "application/pdf",
          "url" : "/Binary/discharge-summary789.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-03"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  }]
}