US Core Implementation Guide
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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 8.0.0-ballot built by the FHIR (HL7ยฎ FHIRยฎ 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: 8.0.0-ballot
Standards status: Trial-use Maturity Level: 3 Computable Name: USCoreDocumentReferenceProfile
Other Identifiers: OID:2.16.840.1.113883.4.642.40.2.42.23

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 โ€” 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:

Changes since version 7.0.0:

  • No changes

    • 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 value:$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
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!ฮฃ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... identifier Sฮฃ 0..* Identifier Other identifiers for the document
    ele-1: All FHIR elements must have a @value or children
    ... status ?!Sฮฃ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ele-1: All FHIR elements must have a @value or children
    ... type Sฮฃ 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

    ele-1: All FHIR elements must have a @value or children
    ... Slices for category Sฮฃ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


    ele-1: All FHIR elements must have a @value or children
    .... category:uscore ฮฃ 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


    ele-1: All FHIR elements must have a @value or children
    ... subject Sฮฃ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
    ele-1: All FHIR elements must have a @value or children
    ... date Sฮฃ 0..1 instant When this document reference was created
    ele-1: All FHIR elements must have a @value or children
    ... author Sฮฃ 0..* Reference(US Core Practitioner Profile) Who and/or what authored the document
    ele-1: All FHIR elements must have a @value or children
    ... content Sฮฃ 1..* BackboneElement Document referenced
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... attachment SฮฃC 1..1 Attachment Where to access the document
    ele-1: All FHIR elements must have a @value or children
    us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
    ..... contentType Sฮฃ 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.


    ele-1: All FHIR elements must have a @value or children
    Example General: text/plain; charset=UTF-8, image/png
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ele-1: All FHIR elements must have a @value or children
    ..... url SฮฃC 0..1 url Uri where the data can be found
    ele-1: All FHIR elements must have a @value or children
    Example General: http://www.acme.com/logo-small.png
    .... format Sฮฃ 0..1 Coding Format/content rules for the document
    Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
    ele-1: All FHIR elements must have a @value or children
    ... context Sฮฃ 0..1 BackboneElement Clinical context of document
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
    ele-1: All FHIR elements must have a @value or children
    .... period Sฮฃ 0..1 Period Time of service that is being documented
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DocumentReference.statusrequiredDocumentReferenceStatus
    http://hl7.org/fhir/ValueSet/document-reference-status
    from the FHIR Standard
    DocumentReference.typerequiredUSCoreDocumentReferenceType
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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 ฮฃ 0..1 id Logical id of this artifact
    ... meta ฮฃ 0..1 Meta Metadata about the resource
    ... implicitRules ?!ฮฃ 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 ฮฃ 0..1 Identifier Master Version Specific Identifier
    ... identifier Sฮฃ 0..* Identifier Other identifiers for the document
    ... status ?!Sฮฃ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... docStatus ฮฃ 0..1 code preliminary | final | amended | entered-in-error
    Binding: CompositionStatus (required): Status of the underlying document.

    ... type Sฮฃ 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 Sฮฃ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


    .... category:uscore ฮฃ 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 Sฮฃ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
    ... date Sฮฃ 0..1 instant When this document reference was created
    ... author Sฮฃ 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 ฮฃ 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 ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code ฮฃ 1..1 code replaces | transforms | signs | appends
    Binding: DocumentRelationshipType (required): The type of relationship between documents.

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


    ... content Sฮฃ 1..* BackboneElement Document referenced
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SฮฃC 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 Sฮฃ 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 ฮฃ 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 SฮฃC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    ..... size ฮฃ 0..1 unsignedInt Number of bytes of content (if url provided)
    ..... hash ฮฃ 0..1 base64Binary Hash of the data (sha-1, base64ed)
    ..... title ฮฃ 0..1 string Label to display in place of the data
    Example General: Official Corporate Logo
    ..... creation ฮฃ 0..1 dateTime Date attachment was first created
    .... format Sฮฃ 0..1 Coding Format/content rules for the document
    Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
    ... context Sฮฃ 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 ?!ฮฃ 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 Sฮฃ 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
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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 value:$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
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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
    dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
    dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
    dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
    dom-5: If a resource is contained in another resource, it SHALL NOT have a security label
    dom-6: A resource should have narrative for robust management
    ... implicitRules ?!ฮฃ 0..1 uri A set of rules under which this content was created
    ele-1: All FHIR elements must have a @value or children
    ... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    ... identifier Sฮฃ 0..* Identifier Other identifiers for the document
    ele-1: All FHIR elements must have a @value or children
    ... status ?!Sฮฃ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ele-1: All FHIR elements must have a @value or children
    ... type Sฮฃ 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

    ele-1: All FHIR elements must have a @value or children
    ... Slices for category Sฮฃ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


    ele-1: All FHIR elements must have a @value or children
    .... category:uscore ฮฃ 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


    ele-1: All FHIR elements must have a @value or children
    ... subject Sฮฃ 1..1 Reference(US Core Patient Profile) Who/what is the subject of the document
    ele-1: All FHIR elements must have a @value or children
    ... date Sฮฃ 0..1 instant When this document reference was created
    ele-1: All FHIR elements must have a @value or children
    ... author Sฮฃ 0..* Reference(US Core Practitioner Profile) Who and/or what authored the document
    ele-1: All FHIR elements must have a @value or children
    ... content Sฮฃ 1..* BackboneElement Document referenced
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... attachment SฮฃC 1..1 Attachment Where to access the document
    ele-1: All FHIR elements must have a @value or children
    us-core-6: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present.
    ..... contentType Sฮฃ 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.


    ele-1: All FHIR elements must have a @value or children
    Example General: text/plain; charset=UTF-8, image/png
    ..... data SC 0..1 base64Binary Data inline, base64ed
    ele-1: All FHIR elements must have a @value or children
    ..... url SฮฃC 0..1 url Uri where the data can be found
    ele-1: All FHIR elements must have a @value or children
    Example General: http://www.acme.com/logo-small.png
    .... format Sฮฃ 0..1 Coding Format/content rules for the document
    Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
    ele-1: All FHIR elements must have a @value or children
    ... context Sฮฃ 0..1 BackboneElement Clinical context of document
    ele-1: All FHIR elements must have a @value or children
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    ele-1: All FHIR elements must have a @value or children
    ext-1: Must have either extensions or value[x], not both
    .... encounter S 0..1 Reference(US Core Encounter Profile) Context of the document content
    ele-1: All FHIR elements must have a @value or children
    .... period Sฮฃ 0..1 Period Time of service that is being documented
    ele-1: All FHIR elements must have a @value or children

    doco Documentation for this format

    Terminology Bindings

    PathConformanceValueSetURI
    DocumentReference.statusrequiredDocumentReferenceStatus
    http://hl7.org/fhir/ValueSet/document-reference-status
    from the FHIR Standard
    DocumentReference.typerequiredUSCoreDocumentReferenceType
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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 ฮฃ 0..1 id Logical id of this artifact
    ... meta ฮฃ 0..1 Meta Metadata about the resource
    ... implicitRules ?!ฮฃ 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 ฮฃ 0..1 Identifier Master Version Specific Identifier
    ... identifier Sฮฃ 0..* Identifier Other identifiers for the document
    ... status ?!Sฮฃ 1..1 code current | superseded | entered-in-error
    Binding: DocumentReferenceStatus (required)
    ... docStatus ฮฃ 0..1 code preliminary | final | amended | entered-in-error
    Binding: CompositionStatus (required): Status of the underlying document.

    ... type Sฮฃ 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 Sฮฃ 1..* CodeableConcept Categorization of document
    Slice: Unordered, Open by value:$this
    Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.


    .... category:uscore ฮฃ 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 Sฮฃ 1..1 Reference(US Core Patient Profile S | Practitioner | Group | Device) Who/what is the subject of the document
    ... date Sฮฃ 0..1 instant When this document reference was created
    ... author Sฮฃ 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 ฮฃ 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 ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... code ฮฃ 1..1 code replaces | transforms | signs | appends
    Binding: DocumentRelationshipType (required): The type of relationship between documents.

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


    ... content Sฮฃ 1..* BackboneElement Document referenced
    .... id 0..1 string Unique id for inter-element referencing
    .... extension 0..* Extension Additional content defined by implementations
    .... modifierExtension ?!ฮฃ 0..* Extension Extensions that cannot be ignored even if unrecognized
    .... attachment SฮฃC 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 Sฮฃ 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 ฮฃ 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 SฮฃC 0..1 url Uri where the data can be found
    Example General: http://www.acme.com/logo-small.png
    ..... size ฮฃ 0..1 unsignedInt Number of bytes of content (if url provided)
    ..... hash ฮฃ 0..1 base64Binary Hash of the data (sha-1, base64ed)
    ..... title ฮฃ 0..1 string Label to display in place of the data
    Example General: Official Corporate Logo
    ..... creation ฮฃ 0..1 dateTime Date attachment was first created
    .... format Sฮฃ 0..1 Coding Format/content rules for the document
    Binding: HL7 ValueSet of Format Codes for use with Document Sharing (extensible)
    ... context Sฮฃ 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 ?!ฮฃ 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 Sฮฃ 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
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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
    http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type
    from this IG
    Additional Bindings Purpose
    US Core Clinical Note Type Min Binding
    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
    http://hl7.org/fhir/ValueSet/languages
    from the FHIR Standard
    Additional Bindings Purpose
    AllLanguages Max Binding
    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 bothย 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|8.0.0-ballot"]
  },
  "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"
    }
  }]
}