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
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:
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:
Each DocumentReference Must Support:
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.
Profile Specific Implementation Guidance:
DocumentReference.type
binding Must Support, at a minimum, the 5 Common Clinical Notes and may extend to the whole US Core DocumentReference Type Value Seturn:hl7-org:sdwg:ccda-structuredBody:2.1
DocumentReference.attachment.url
or the content as inline base64 encoded data using DocumentReference.attachment.data
.
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.
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
.DocumentReference.custodian
or accessible in the Provenance resource targeting the DocumentReference using Provenance.agent.who
or Provenance.agent.onBehalfOf
.
Encounter.serviceProvider
.Usage:
Changes since version 7.0.0:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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'
| ||||
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 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
implicitRules | ?!ฮฃ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Sฮฃ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!Sฮฃ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
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'
| ||||
Slices for category | Sฮฃ | 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 | 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) | 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) | Who and/or what authored the document | ||||
content | Sฮฃ | 1..* | BackboneElement | Document referenced | ||||
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. | ||||
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 | ||||
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 | ||||
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 | ||||
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 | ||||
period | Sฮฃ | 0..1 | Period | Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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.
| |||||
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'
| ||||
Slices for category | Sฮฃ | 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 | 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.
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime 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.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements
Must-Support: 16 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Differential View
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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'
| ||||
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 | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
implicitRules | ?!ฮฃ | 0..1 | uri | A set of rules under which this content was created | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Sฮฃ | 0..* | Identifier | Other identifiers for the document | ||||
status | ?!Sฮฃ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required) | ||||
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'
| ||||
Slices for category | Sฮฃ | 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 | 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) | 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) | Who and/or what authored the document | ||||
content | Sฮฃ | 1..* | BackboneElement | Document referenced | ||||
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. | ||||
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 | ||||
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 | ||||
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 | ||||
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 | ||||
period | Sฮฃ | 0..1 | Period | Time of service that is being documented | ||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.contentType | required | Mime Types (a valid code from urn:ietf:bcp:13 )http://hl7.org/fhir/ValueSet/mimetypes|4.0.1 from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
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.
| |||||
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'
| ||||
Slices for category | Sฮฃ | 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 | 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.
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 | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | required | USCoreDocumentReferenceType
http://hl7.org/fhir/us/core/ValueSet/us-core-documentreference-type from this IG | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.category:uscore | required | USCoreDocumentReferenceCategory (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.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.attachment.contentType | required | Mime 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.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.content.format | extensible | HL7FormatCodeshttp://terminology.hl7.org/ValueSet/v3-HL7FormatCodes | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Id | Grade | Path(s) | Details | Requirements |
us-core-6 | error | DocumentReference.content.attachment | DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. : url.exists() or data.exists() |
This structure is derived from DocumentReference
Summary
Mandatory: 3 elements
Must-Support: 16 elements
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Maturity: 3
Other representations of profile: CSV, Excel, Schematron
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.
Servers providing access to clniical note data SHALL support these US Core SMART Scopes:
<patient|user|system>/DocumentReference.rs
Servers providing access to clniical note data SHOULD support these US Core SMART Scopes:
<patient|user|system>.DocumentReference.rs?category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note
The following search parameters and search parameter combinations SHALL be supported:
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:
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)
SHALL support searching for all documentreferences for a patient using the patient
search parameter:
GET [base]/DocumentReference?patient={Type/}[id]
Example:
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)
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:
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)
patient
and category
and date
search parameters:
date
comparators: gt,lt,ge,le
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:
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)
SHALL support searching using the combination of the patient
and type
search parameters:
GET [base]/DocumentReference?patient={Type/}[id]&type={system|}[code]
Example:
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)
The following search parameter combinations SHOULD be supported:
patient
and status
search parameters:
status
(e.g.status={system|}[code],{system|}[code],...
)GET [base]/DocumentReference?patient={Type/}[id]&status={system|}[code]{,{system|}[code],...}
Example:
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)
patient
and type
and period
search parameters:
period
comparators: gt,lt,ge,le
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:
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)
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" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-name",
"valueString" : "Discharge Summary Example"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-description",
"valueMarkdown" : "This is a discharge summary example for the *US Core DocumentReference*. It is used in the [Write Note Example](StructureDefinition-us-core-documentreference.html#mandatory-operation)."
}],
"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 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."
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",
"meta" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-name",
"valueString" : "Docref Example 1"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-description",
"valueMarkdown" : "This bundle is a the response to a $docref operation and contains an example *US Core DocumentReference*. It is used in [Example 1: Request the latest CCD](StructureDefinition-us-core-documentreference.html#mandatory-operation)."
}]
},
"type" : "searchset",
"total" : 1,
"link" : [{
"relation" : "self",
"url" : "http://example.org/DocumentReference/$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",
"meta" : {
"extension" : [{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-name",
"valueString" : "Docref Example 2"
},
{
"url" : "http://hl7.org/fhir/StructureDefinition/instance-description",
"valueMarkdown" : "This bundle is a the response to a $docref operation and contains an examples of *US Core DocumentReference*. It is used in [Example 2: Request Procedure Notes and Discharge Summaries for 2019](StructureDefinition-us-core-documentreference.html#mandatory-operation)."
}]
},
"type" : "searchset",
"total" : 3,
"link" : [{
"relation" : "self",
"url" : "http://example.org/DocumentReference/$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" : {
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