US Core Maturity: 5

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 author¹
4. a code identifying the specific implementation requirements that the document conforms to — 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."

¹ see guidance below

Profile Specific Implementation Guidance

This section provides detailed implementation guidance for the US Core Profile to support implementation and certification.

• See Clinical Notes
• The DocumentReference.type binding Must Support, at a minimum, the 11 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.
• For C-CDA Clinical Documents
  • The format code in DocumentReference.content.format is "urn:hl7-org:sdwg:ccda-structuredBody:2.1".
  • For other CDA documents, Servers SHOULD select the appropriate format code from the HL7 ValueSet of Format Codes for use with Document Sharing.
• The DocumentReference resources can represent the referenced content using either an address where the document can be retrieved using DocumentReference.content.attachment.url or the content as inline base64 encoded data using DocumentReference.content.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 DocumentReference.content.attachment.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 referenced document or file is hosted on a server outside the FHIR server, it SHOULD be securely accessible using the same authorization credentials that were used to access the FHIR server.^§ This reduces complexity for the client and improves the user experience.
  • 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.

• ¹The profile element DocumentReference.author communicates the individual level provenance author data corresponding to the U.S. Core Data for Interoperability (USCDI) Provenance Author Data Elements.

• For the USCDI Adverse Events Data Class, a change in a patient condition documented in a clinical note can be what both USCDI Adverse Event Condition and Adverse Event Outcome describe. Adverse events are recorded as ordinary clinical events and are not tagged as adverse events; see the Adverse Events: Clinical Records and Patient Safety Reporting page.

Changes since version 9.0.0:

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.identifier	S This element must be supported. Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.type	S This element must be supported. Σ This element is included in summaries.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported. Σ This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.category:uscore	Σ This element is included in summaries.	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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	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
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. Σ This element is included in summaries. C	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.format	S This element must be supported. Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4

Constraints

Id	Grade	Path(s)	Description	Expression
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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.identifier	S This element must be supported.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	S This element must be supported.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.type	S This element must be supported.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported.	1..*	CodeableConcept	Categorization of document Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.content	S This element must be supported.	1..*	BackboneElement	Document referenced
DocumentReference.content.attachment	S This element must be supported. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.contentType	S This element must be supported.	0..1	code	Mime type of the content, with charset etc.
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. C	0..1	url	Uri where the data can be found
DocumentReference.content.format	S This element must be supported.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.period	S This element must be supported.	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4

Constraints

Id	Grade	Path(s)	Description	Expression
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    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	Σ This element is included in summaries.	0..1	Identifier	Master Version Specific Identifier
DocumentReference.identifier	S This element must be supported. Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
DocumentReference.type	S This element must be supported. Σ This element is included in summaries.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported. Σ This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.category:uscore	Σ This element is included in summaries.	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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
DocumentReference.custodian		0..1	Reference(Organization)	Organization which maintains the document
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	Relationships to other documents
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(DocumentReference)	Target of the relationship
DocumentReference.description	Σ This element is included in summaries.	0..1	string	Human-readable description
DocumentReference.securityLabel	Σ This element is included in summaries.	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	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
DocumentReference.content.attachment.language	Σ This element is included in summaries.	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. Σ This element is included in summaries. C	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	S This element must be supported. Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
DocumentReference.context.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
DocumentReference.context.facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
DocumentReference.context.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).
DocumentReference.context.sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
DocumentReference.context.related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📍4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.identifier	S This element must be supported. Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.type	S This element must be supported. Σ This element is included in summaries.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported. Σ This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.category:uscore	Σ This element is included in summaries.	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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	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
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. Σ This element is included in summaries. C	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.format	S This element must be supported. Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4

Constraints

Id	Grade	Path(s)	Description	Expression
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()

Differential View

This structure is derived from DocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.identifier	S This element must be supported.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	S This element must be supported.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.type	S This element must be supported.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported.	1..*	CodeableConcept	Categorization of document Slice: Unordered, Open by value:$this Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.content	S This element must be supported.	1..*	BackboneElement	Document referenced
DocumentReference.content.attachment	S This element must be supported. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.contentType	S This element must be supported.	0..1	code	Mime type of the content, with charset etc.
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. C	0..1	url	Uri where the data can be found
DocumentReference.content.format	S This element must be supported.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.period	S This element must be supported.	0..1	Period	Time of service that is being documented
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4

Constraints

Id	Grade	Path(s)	Description	Expression
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    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
DocumentReference.id	Σ This element is included in summaries.	0..1	id	Logical id of this artifact
DocumentReference.meta	Σ This element is included in summaries.	0..1	Meta	Metadata about the resource
DocumentReference.implicitRules	?! This element is a modifier element. Σ This element is included in summaries.	0..1	uri	A set of rules under which this content was created
DocumentReference.language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
DocumentReference.contained		0..*	Resource	Contained, inline Resources
DocumentReference.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.modifierExtension	?! This element is a modifier element.	0..*	Extension	Extensions that cannot be ignored
DocumentReference.masterIdentifier	Σ This element is included in summaries.	0..1	Identifier	Master Version Specific Identifier
DocumentReference.identifier	S This element must be supported. Σ This element is included in summaries.	0..*	Identifier	Other identifiers for the document
DocumentReference.status	?! This element is a modifier element. S This element must be supported. Σ This element is included in summaries.	1..1	code	current | superseded | entered-in-error Binding: DocumentReferenceStatus (required)
DocumentReference.docStatus	Σ This element is included in summaries.	0..1	code	preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document.
DocumentReference.type	S This element must be supported. Σ This element is included in summaries.	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 Bindings Purpose Documentation US Core Clinical Note Type Min Binding Must Support, at a minimum, the 11 "Common Clinical Notes" Types
DocumentReference.Slices for category	S This element must be supported. Σ This element is included in summaries.	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. Slicing Note: The rules on this element (including its children) apply to all the slices, but are not repeated in them
DocumentReference.Slices for category.category:uscore	Σ This element is included in summaries.	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 in other slices, see Required Bindings When Slicing by Value Sets
DocumentReference.subject	S This element must be supported. Σ This element is included in summaries.	1..1	Reference(US Core Patient Profile S This type must be supported. | Practitioner | Group | US Core Device Profile)	Who/what is the subject of the document
DocumentReference.date	S This element must be supported. Σ This element is included in summaries.	0..1	instant	When this document reference was created
DocumentReference.author	S This element must be supported. Σ This element is included in summaries.	0..*	Reference(US Core Practitioner Profile S This type must be supported. | US Core Organization Profile | US Core Patient Profile | US Core PractitionerRole Profile | US Core RelatedPerson Profile | US Core Device Profile)	Who and/or what authored the document
DocumentReference.authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
DocumentReference.custodian		0..1	Reference(Organization)	Organization which maintains the document
DocumentReference.relatesTo	Σ This element is included in summaries.	0..*	BackboneElement	Relationships to other documents
DocumentReference.relatesTo.id		0..1	string	Unique id for inter-element referencing
DocumentReference.relatesTo.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.relatesTo.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.relatesTo.code	Σ This element is included in summaries.	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
DocumentReference.relatesTo.target	Σ This element is included in summaries.	1..1	Reference(DocumentReference)	Target of the relationship
DocumentReference.description	Σ This element is included in summaries.	0..1	string	Human-readable description
DocumentReference.securityLabel	Σ This element is included in summaries.	0..*	CodeableConcept	Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
DocumentReference.content	S This element must be supported. Σ This element is included in summaries.	1..*	BackboneElement	Document referenced
DocumentReference.content.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.content.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.content.attachment	S This element must be supported. Σ This element is included in summaries. C	1..1	Attachment	Where to access the document Constraints: us-core-6
DocumentReference.content.attachment.id		0..1	string	Unique id for inter-element referencing
DocumentReference.content.attachment.extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
DocumentReference.content.attachment.contentType	S This element must be supported. Σ This element is included in summaries.	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
DocumentReference.content.attachment.language	Σ This element is included in summaries.	0..1	code	Human language of the content (BCP-47) Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
DocumentReference.content.attachment.data	S This element must be supported. C	0..1	base64Binary	Data inline, base64ed
DocumentReference.content.attachment.url	S This element must be supported. Σ This element is included in summaries. C	0..1	url	Uri where the data can be found Example General: http://www.acme.com/logo-small.png
DocumentReference.content.attachment.size	Σ This element is included in summaries.	0..1	unsignedInt	Number of bytes of content (if url provided)
DocumentReference.content.attachment.hash	Σ This element is included in summaries.	0..1	base64Binary	Hash of the data (sha-1, base64ed)
DocumentReference.content.attachment.title	Σ This element is included in summaries.	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
DocumentReference.content.attachment.creation	Σ This element is included in summaries.	0..1	dateTime	Date attachment was first created
DocumentReference.content.format	S This element must be supported. Σ This element is included in summaries.	0..1	Coding	Format/content rules for the document Binding: HL7FormatCodes (2.1.0) (extensible)
DocumentReference.context	S This element must be supported. Σ This element is included in summaries.	0..1	BackboneElement	Clinical context of document
DocumentReference.context.id		0..1	string	Unique id for inter-element referencing
DocumentReference.context.extension		0..*	Extension	Additional content defined by implementations
DocumentReference.context.modifierExtension	?! This element is a modifier element. Σ This element is included in summaries.	0..*	Extension	Extensions that cannot be ignored even if unrecognized
DocumentReference.context.encounter	S This element must be supported.	0..1	Reference(US Core Encounter Profile)	Context of the document content
DocumentReference.context.event		0..*	CodeableConcept	Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
DocumentReference.context.period	S This element must be supported. Σ This element is included in summaries.	0..1	Period	Time of service that is being documented
DocumentReference.context.facilityType		0..1	CodeableConcept	Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
DocumentReference.context.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).
DocumentReference.context.sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
DocumentReference.context.related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📦4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	required	US Core DocumentReference Type	📦10.0.0-ballot	This IG
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category:uscore	Base	required	US Core DocumentReference Category	📦10.0.0-ballot	This IG
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	extensible	HL7 ValueSet of Format Codes for use with Document Sharing	📍2.1.0	THO v7.4
DocumentReference.context.​event	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.4
DocumentReference.context.​facilityType	Base	example	Facility Type Code Value Set	📍4.0.1	FHIR Std.
DocumentReference.context.​practiceSetting	Base	example	Practice Setting Code Value Set	📍4.0.1	FHIR Std.

Constraints

Id	Grade	Path(s)	Description	Expression
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:

• US Core Patient Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-patient)
• US Core Device Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-device)
• US Core Practitioner Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitioner)
• US Core Organization Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-organization)
• US Core PractitionerRole Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-practitionerrole)
• US Core RelatedPerson Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-relatedperson)
• US Core Encounter Profile (http://hl7.org/fhir/us/core/StructureDefinition/us-core-encounter)

Slices

This structure defines the following Slices:

• The element 1 is sliced based on the value of DocumentReference.category

Maturity: 5

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 clinical note data SHALL support these US Core SMART Scopes:

• resource level scopes: <patient|user|system>/DocumentReference.rs ^§

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

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

Mandatory Search Parameters:

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

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

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

   Examples:

   1. GET [base]/DocumentReference/2169591

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

   Implementation Notes: Fetches a single US Core DocumentReference Profile or a search Bundle containing a US Core DocumentReference Profile resource matching the id. 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]. (see Parameters for all resources).

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

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

   Example:

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

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

3. SHALL support searching for all clinical notes for a given patient using the combination of the patient and category search parameters

   GET [base]/DocumentReference?patient={Patient/}[id]&category={system|}[search_code]

   Example:

   1. GET [base]/DocumentReference?patient=Patient/1137192&category=http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category|clinical-note

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

4. SHALL support searching for all clinical notes for a given patient by date (for example, since 2019) using the combination of the patient and category and date search parameters

   • Including optional support for AND search on date (e.g.date=[date]&date=[date]&...)

   • Including support for these date comparators: "gt", "lt", "ge", "le"

   GET [base]/DocumentReference?patient={Patient/}[id]&category={system|}[search_code]&date={gt|lt|ge|le}[dateTime]{&date={gt|lt|ge|le}[dateTime]&...}

   Example:

   1. GET [base]/DocumentReference?patient=Patient/1137192&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 US Core DocumentReference Profile resources for the specified patient and category = "clinical-note" and date. See the implementation notes above for how to access the actual document. ( see how to search by reference and how to search by token and how to search by date).

5. SHALL support searching for a specific note type for a patient using the combination of the patient and type search parameters

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

   Example:

   1. GET [base]/DocumentReference?patient=Patient/1137192&type=http://loinc.org|18842-5

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

Optional Search Parameters:

The following search parameters and search parameter combinations SHOULD be supported

1. SHOULD support searching for all documents for a patient for a given status (for example completed reports ) using the combination of the patient and status search parameters

   • Including support OR search on status (e.g.status={system|}[code],{system|}[code],...)

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

   Example:

   1. GET [base]/DocumentReference?patient=Patient/1137192&status=completed

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

2. SHOULD support searching for a document for a patient by type and a clinically relevent date using the combination of the patient and type and period search parameters

   • Including optional support for AND search on period (e.g.period=[date]&period=[date]&...)

   • Including support for these period comparators: "gt", "lt", "ge", "le"

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

   Example:

   1. GET [base]/DocumentReference?patient=Patient/1137192&type=http://loinc.org|18842-5&period=ge2020-01-01T00:00:00Z

   Implementation Notes: Fetches a bundle of all US Core DocumentReference Profile resources for the specified patient and type and period. See the implementation notes above for how to access the actual document. ( see 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

Click Here To See Example

{
  "resourceType" : "DocumentReference",
  "meta" : {
    "profile" : ["http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference|10.0.0-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"
    }]
  }
}

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 is 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

Click Here To See Example

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

HTTP/1.1 200 OK
[other headers]

{
  "resourceType" : "Bundle",
  "id" : "docref-example-1",
  "type" : "searchset",
  "total" : 1,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/fhir/DocumentReference/$docref?patient=123"
  }],
  "entry" : [{
    "fullUrl" : "http://example.org/fhir/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" : "http://example.org/fhir/Binary/1-note",
          "title" : "URI where the data can be found: http://example.org/fhir/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

Click Here To See Example

{
    "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
        }
    ]
}

HTTP/1.1 200 OK
[other headers]

{
  "resourceType" : "Bundle",
  "id" : "docref-example-2",
  "type" : "searchset",
  "total" : 3,
  "link" : [{
    "relation" : "self",
    "url" : "http://example.org/fhir/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/fhir/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" : "http://example.org/fhir/Binary/procedure-note123.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-02"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/fhir/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" : "http://example.org/fhir/Binary/procedure-note456.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-06-01",
          "end" : "2019-06-01"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  },
  {
    "fullUrl" : "http://example.org/fhir/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" : "http://example.org/fhir/Binary/discharge-summary789.pdf"
        }
      }],
      "context" : {
        "period" : {
          "start" : "2019-03-01",
          "end" : "2019-03-03"
        }
      }
    },
    "search" : {
      "mode" : "match"
    }
  }]
}