Release 4B

This page is part of the FHIR Specification (v4.3.0: R4B - STU). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.42 Resource DocumentReference - Content

Structured Documents Work Group Maturity Level: 3 Trial Use Security Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

2.42.1 Scope and Usage

A DocumentReference resource is used to index a document, clinical note, and other binary objects to make them available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes its own context (e.g., what subject, author, etc. can be displayed to the user), and has defined update management. The DocumentReference resource can be used with any document format that has a recognized mime type and that conforms to this definition.

Typically, DocumentReference resources are used in document indexing systems, such as IHE XDS , such as profiled in IHE Mobile access to Health Documents .

DocumentReference is metadata describing a document such as:

  • CDA documents in FHIR systems
  • FHIR documents stored elsewhere (i.e. registry/repository following the XDS model)
  • PDF documents , Scanned Paper, and digital records of faxes
  • Clinical Notes in various forms
  • Image files (e.g., JPEG, GIF, TIFF)
  • Non-Standard formats (e.g., WORD)
  • Other kinds of documents, such as records of prescriptions or immunizations

2.42.2 Boundaries and Relationships

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. This resource is mainly intended for general references to assembled documents.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource, or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet, or a DICOM exchange, or an HL7 v2 message query - though the way each of these service calls works must be specified in some external standard or other documentation.

A DocumentReference describes some other document. This means that there are two sets of provenance information relevant here: the provenance of the document, and the provenance of the document reference. Sometimes, the provenance information is closely related, as when the document producer also produces the document reference, but in other workflows, the document reference is generated later by other actors. In the DocumentReference resource, the meta content refers to the provenance of the reference itself, while the content described below concerns the document it references. Like all resources, there is overlap between the information in the resource directly, and in the general Provenance resource. This is discussed as part of the description of the Provenance resource.

2.42.3 References

This resource is referenced by AdverseEvent, CarePlan, Communication, CommunicationRequest, Consent, Contract, DeviceRequest, DeviceUseStatement, itself, FamilyMemberHistory, GuidanceResponse, ImagingStudy, MedicationKnowledge, MedicinalProductDefinition, Observation, Procedure, RequestGroup, RiskAssessment, ServiceRequest, SubstanceDefinition and SupplyRequest.

This resource implements the Event pattern.

2.42.4 Resource Content

Structure

Name Flags Card. Type Description & Constraints doco
.. DocumentReference TU DomainResource A reference to a document
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... masterIdentifier Σ 0..1Identifier Master Version Specific Identifier
... identifier Σ 0..*Identifier Other identifiers for the document
... status ?! Σ 1..1code current | superseded | entered-in-error
DocumentReferenceStatus (Required)
... type Σ 0..1CodeableConcept Kind of document (LOINC if possible)
FHIR Document Type Codes (Preferred)
... category Σ 0..*CodeableConcept Categorization of document
Document Class Value Set (Example)
... subject Σ 0..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... date Σ 0..1instant When this document reference was created
... author Σ 0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ 0..*BackboneElement Relationships to other documents
.... code Σ 1..1code replaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target Σ 1..1Reference(DocumentReference)Target of the relationship
... description Σ 0..1string Human-readable description
... securityLabel Σ 0..*CodeableConcept Document security-tags
SecurityLabels (Extensible)
... content Σ 1..*BackboneElement Document referenced
.... attachment Σ 1..1Attachment Where to access the document
.... format Σ 0..1Coding Format/content rules for the document
DocumentReference Format Code Set (Preferred)
... context Σ 0..1BackboneElement Clinical context of document
.... encounter 0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConcept Main clinical acts documented
v3 Code System ActCode (Example)
.... period Σ 0..1Period Time of service that is being documented
.... facilityType 0..1CodeableConcept Kind of facility where patient was seen
Facility Type Code Value Set (Example)
.... practiceSetting 0..1CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Practice Setting Code Value Set (Example)
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Any)Related identifiers or resources

doco Documentation for this format

UML Diagram (Legend)

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier [0..1]Other identifiers associated with the document, including version independent identifiersidentifier : Identifier [0..*]The status of this document reference (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)DocumentReferenceStatus! »The status of the underlying documentdocStatus : code [0..1] « null (Strength=Required)CompositionStatus! »Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referencedtype : CodeableConcept [0..1] « null (Strength=Preferred)FHIRDocumentTypeCodes? »A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.typecategory : CodeableConcept [0..*] « null (Strength=Example)DocumentClassValueSet?? »Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference [0..1] « Patient|Practitioner|Group|Device »When the document reference was createddate : instant [0..1]Identifies who is responsible for adding the information to the documentauthor : Reference [0..*] « Practitioner|PractitionerRole| Organization|Device|Patient|RelatedPerson »Which person or organization authenticates that this document is validauthenticator : Reference [0..1] « Practitioner|PractitionerRole| Organization »Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference [0..1] « Organization »Human-readable description of the source documentdescription : string [0..1]A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers tosecurityLabel : CodeableConcept [0..*] « null (Strength=Extensible)All Security Labels+ »RelatesToThe type of relationship that this document has with anther documentcode : code [1..1] « null (Strength=Required)DocumentRelationshipType! »The target document of this relationshiptarget : Reference [1..1] « DocumentReference »ContentThe document or URL of the document along with critical metadata to prove content has integrityattachment : Attachment [1..1]An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : Coding [0..1] « null (Strength=Preferred)DocumentReferenceFormatCodeSet? »ContextDescribes the clinical encounter or type of care that the document content is associated withencounter : Reference [0..*] « Encounter|EpisodeOfCare »This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept [0..*] « null (Strength=Example)ActCode?? »The time period over which the service that is described by the document was providedperiod : Period [0..1]The kind of facility where the patient was seenfacilityType : CodeableConcept [0..1] « null (Strength=Example)FacilityTypeCodeValueSet?? »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept [0..1] « null (Strength=Example) PracticeSettingCodeValueSet?? »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference [0..1] « Patient »Related identifiers or resources associated with the DocumentReferencerelated : Reference [0..*] « Any »Relationships that this document has with other document references that already existrelatesTo [0..*]The document and format referenced. There may be multiple content element repetitions, each with a different formatcontent [1..*]The clinical context in which the document was preparedcontext [0..1]

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier  Master Version Specific Identifier  --></masterIdentifier>
 <identifier><!-- 0..* Identifier  Other identifiers for the document  --></identifier>
 <status value="[code ]"/><!-- 1..1 current | superseded | entered-in-error  -->
 <docStatus value="[code ]"/><!-- 0..1 preliminary | final | amended | entered-in-error  -->
 <type><!-- 0..1 CodeableConcept  Kind of document (LOINC if possible)  --></type>
 <category><!-- 0..* CodeableConcept  Categorization of document  --></category>
 <subject><!-- 0..1 Reference(Device|Group|Patient|Practitioner) Who/what is the subject of the document  --></subject>
 <date value="[instant ]"/><!-- 0..1 When this document reference was created  -->
 <author><!-- 0..* Reference(Device|Organization|Patient|Practitioner|
 PractitionerRole|RelatedPerson) Who and/or what authored the document  --></author>
 <authenticator><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Who/what authenticated the document  --></authenticator>
 <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document  --></custodian>
 <relatesTo> <!-- 0..* Relationships to other documents -->
 <code value="[code ]"/><!-- 1..1 replaces | transforms | signs | appends  -->
 <target><!-- 1..1 Reference(DocumentReference) Target of the relationship  --></target>
 </relatesTo>
 <description value="[string ]"/><!-- 0..1 Human-readable description  -->
 <securityLabel><!-- 0..* CodeableConcept  Document security-tags  --></securityLabel>
 <content> <!-- 1..* Document referenced -->
 <attachment><!-- 1..1 Attachment  Where to access the document  --></attachment>
 <format><!-- 0..1 Coding  Format/content rules for the document  --></format>
 </content>
 <context> <!-- 0..1 Clinical context of document -->
 <encounter><!-- 0..* Reference(Encounter|EpisodeOfCare) Context of the document content  --></encounter>
 <event><!-- 0..* CodeableConcept  Main clinical acts documented   --></event>
 <period><!-- 0..1 Period  Time of service that is being documented  --></period>
 <facilityType><!-- 0..1 CodeableConcept  Kind of facility where patient was seen  --></facilityType>
 <practiceSetting><!-- 0..1 CodeableConcept  Additional details about where the content was created (e.g. clinical specialty)  --></practiceSetting>
 <sourcePatientInfo><!-- 0..1 Reference(Patient) Patient demographics from source  --></sourcePatientInfo>
 <related><!-- 0..* Reference(Any) Related identifiers or resources  --></related>
 </context>
</DocumentReference>

JSON Template

{doco 
 "resourceType" : "DocumentReference",
 // from Resource: id, meta, implicitRules, and language
 // from DomainResource: text, contained, extension, and modifierExtension
 "masterIdentifier" : { Identifier  }, // Master Version Specific Identifier 
 "identifier" : [{ Identifier  }], // Other identifiers for the document 
 "status" : "<code >", // R! current | superseded | entered-in-error 
 "docStatus" : "<code >", // preliminary | final | amended | entered-in-error 
 "type" : { CodeableConcept  }, // Kind of document (LOINC if possible) 
 "category" : [{ CodeableConcept  }], // Categorization of document 
 "subject" : { Reference(Device|Group|Patient|Practitioner) }, // Who/what is the subject of the document 
 "date" : "<instant >", // When this document reference was created 
 "author" : [{ Reference(Device|Organization|Patient|Practitioner|
 PractitionerRole|RelatedPerson) }], // Who and/or what authored the document 
 "authenticator" : { Reference(Organization|Practitioner|PractitionerRole) }, // Who/what authenticated the document 
 "custodian" : { Reference(Organization) }, // Organization which maintains the document 
 "relatesTo" : [{ // Relationships to other documents 
 "code" : "<code >", // R! replaces | transforms | signs | appends 
 "target" : { Reference(DocumentReference) } // R! Target of the relationship 
 }],
 "description" : "<string >", // Human-readable description 
 "securityLabel" : [{ CodeableConcept  }], // Document security-tags 
 "content" : [{ // R! Document referenced 
 "attachment" : { Attachment  }, // R! Where to access the document 
 "format" : { Coding  } // Format/content rules for the document 
 }],
 "context" : { // Clinical context of document 
 "encounter" : [{ Reference(Encounter|EpisodeOfCare) }], // Context of the document content 
 "event" : [{ CodeableConcept  }], // Main clinical acts documented  
 "period" : { Period  }, // Time of service that is being documented 
 "facilityType" : { CodeableConcept  }, // Kind of facility where patient was seen 
 "practiceSetting" : { CodeableConcept  }, // Additional details about where the content was created (e.g. clinical specialty) 
 "sourcePatientInfo" : { Reference(Patient) }, // Patient demographics from source 
 "related" : [{ Reference(Any) }] // Related identifiers or resources 
 }
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco 
[ a fhir:DocumentReference;
 fhir:nodeRole fhir:treeRoot; # if this is the parser root
 # from Resource: .id, .meta, .implicitRules, and .language
 # from DomainResource: .text, .contained, .extension, and .modifierExtension
 fhir:DocumentReference.masterIdentifier[ Identifier ]; # 0..1 Master Version Specific Identifier
 fhir:DocumentReference.identifier[ Identifier ], ... ; # 0..* Other identifiers for the document
 fhir:DocumentReference.status[ code ]; # 1..1 current | superseded | entered-in-error
 fhir:DocumentReference.docStatus[ code ]; # 0..1 preliminary | final | amended | entered-in-error
 fhir:DocumentReference.type[ CodeableConcept ]; # 0..1 Kind of document (LOINC if possible)
 fhir:DocumentReference.category[ CodeableConcept ], ... ; # 0..* Categorization of document
 fhir:DocumentReference.subject[ Reference(Device|Group|Patient|Practitioner) ]; # 0..1 Who/what is the subject of the document
 fhir:DocumentReference.date[ instant ]; # 0..1 When this document reference was created
 fhir:DocumentReference.author[ Reference(Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ], ... ; # 0..* Who and/or what authored the document
 fhir:DocumentReference.authenticator[ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Who/what authenticated the document
 fhir:DocumentReference.custodian[ Reference(Organization) ]; # 0..1 Organization which maintains the document
 fhir:DocumentReference.relatesTo[ # 0..* Relationships to other documents
 fhir:DocumentReference.relatesTo.code[ code ]; # 1..1 replaces | transforms | signs | appends
 fhir:DocumentReference.relatesTo.target[ Reference(DocumentReference) ]; # 1..1 Target of the relationship
 ], ...;
 fhir:DocumentReference.description[ string ]; # 0..1 Human-readable description
 fhir:DocumentReference.securityLabel[ CodeableConcept ], ... ; # 0..* Document security-tags
 fhir:DocumentReference.content[ # 1..* Document referenced
 fhir:DocumentReference.content.attachment[ Attachment ]; # 1..1 Where to access the document
 fhir:DocumentReference.content.format[ Coding ]; # 0..1 Format/content rules for the document
 ], ...;
 fhir:DocumentReference.context[ # 0..1 Clinical context of document
 fhir:DocumentReference.context.encounter[ Reference(Encounter|EpisodeOfCare) ], ... ; # 0..* Context of the document content
 fhir:DocumentReference.context.event[ CodeableConcept ], ... ; # 0..* Main clinical acts documented
 fhir:DocumentReference.context.period[ Period ]; # 0..1 Time of service that is being documented
 fhir:DocumentReference.context.facilityType[ CodeableConcept ]; # 0..1 Kind of facility where patient was seen
 fhir:DocumentReference.context.practiceSetting[ CodeableConcept ]; # 0..1 Additional details about where the content was created (e.g. clinical specialty)
 fhir:DocumentReference.context.sourcePatientInfo[ Reference(Patient) ]; # 0..1 Patient demographics from source
 fhir:DocumentReference.context.related[ Reference(Any) ], ... ; # 0..* Related identifiers or resources
 ];
]

Changes since R4

DocumentReference
  • No Changes

See the Full Difference for further information

This analysis is available as XML or JSON.

Conversions between R3 and R4

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)

Structure

Name Flags Card. Type Description & Constraints doco
.. DocumentReference TU DomainResource A reference to a document
Elements defined in Ancestors: id, meta, implicitRules, language, text, contained, extension, modifierExtension
... masterIdentifier Σ 0..1Identifier Master Version Specific Identifier
... identifier Σ 0..*Identifier Other identifiers for the document
... status ?! Σ 1..1code current | superseded | entered-in-error
DocumentReferenceStatus (Required)
... type Σ 0..1CodeableConcept Kind of document (LOINC if possible)
FHIR Document Type Codes (Preferred)
... category Σ 0..*CodeableConcept Categorization of document
Document Class Value Set (Example)
... subject Σ 0..1Reference(Patient | Practitioner | Group | Device)Who/what is the subject of the document
... date Σ 0..1instant When this document reference was created
... author Σ 0..*Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)Who and/or what authored the document
... authenticator 0..1Reference(Practitioner | PractitionerRole | Organization)Who/what authenticated the document
... custodian 0..1Reference(Organization)Organization which maintains the document
... relatesTo Σ 0..*BackboneElement Relationships to other documents
.... code Σ 1..1code replaces | transforms | signs | appends
DocumentRelationshipType (Required)
.... target Σ 1..1Reference(DocumentReference)Target of the relationship
... description Σ 0..1string Human-readable description
... securityLabel Σ 0..*CodeableConcept Document security-tags
SecurityLabels (Extensible)
... content Σ 1..*BackboneElement Document referenced
.... attachment Σ 1..1Attachment Where to access the document
.... format Σ 0..1Coding Format/content rules for the document
DocumentReference Format Code Set (Preferred)
... context Σ 0..1BackboneElement Clinical context of document
.... encounter 0..*Reference(Encounter | EpisodeOfCare)Context of the document content
.... event 0..*CodeableConcept Main clinical acts documented
v3 Code System ActCode (Example)
.... period Σ 0..1Period Time of service that is being documented
.... facilityType 0..1CodeableConcept Kind of facility where patient was seen
Facility Type Code Value Set (Example)
.... practiceSetting 0..1CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Practice Setting Code Value Set (Example)
.... sourcePatientInfo 0..1Reference(Patient)Patient demographics from source
.... related 0..*Reference(Any)Related identifiers or resources

doco Documentation for this format

UML Diagram (Legend)

DocumentReference (DomainResource)Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the documentmasterIdentifier : Identifier [0..1]Other identifiers associated with the document, including version independent identifiersidentifier : Identifier [0..*]The status of this document reference (this element modifies the meaning of other elements)status : code [1..1] « null (Strength=Required)DocumentReferenceStatus! »The status of the underlying documentdocStatus : code [0..1] « null (Strength=Required)CompositionStatus! »Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referencedtype : CodeableConcept [0..1] « null (Strength=Preferred)FHIRDocumentTypeCodes? »A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.typecategory : CodeableConcept [0..*] « null (Strength=Example)DocumentClassValueSet?? »Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)subject : Reference [0..1] « Patient|Practitioner|Group|Device »When the document reference was createddate : instant [0..1]Identifies who is responsible for adding the information to the documentauthor : Reference [0..*] « Practitioner|PractitionerRole| Organization|Device|Patient|RelatedPerson »Which person or organization authenticates that this document is validauthenticator : Reference [0..1] « Practitioner|PractitionerRole| Organization »Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Reference [0..1] « Organization »Human-readable description of the source documentdescription : string [0..1]A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers tosecurityLabel : CodeableConcept [0..*] « null (Strength=Extensible)All Security Labels+ »RelatesToThe type of relationship that this document has with anther documentcode : code [1..1] « null (Strength=Required)DocumentRelationshipType! »The target document of this relationshiptarget : Reference [1..1] « DocumentReference »ContentThe document or URL of the document along with critical metadata to prove content has integrityattachment : Attachment [1..1]An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeTypeformat : Coding [0..1] « null (Strength=Preferred)DocumentReferenceFormatCodeSet? »ContextDescribes the clinical encounter or type of care that the document content is associated withencounter : Reference [0..*] « Encounter|EpisodeOfCare »This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" actevent : CodeableConcept [0..*] « null (Strength=Example)ActCode?? »The time period over which the service that is described by the document was providedperiod : Period [0..1]The kind of facility where the patient was seenfacilityType : CodeableConcept [0..1] « null (Strength=Example)FacilityTypeCodeValueSet?? »This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialtypracticeSetting : CodeableConcept [0..1] « null (Strength=Example) PracticeSettingCodeValueSet?? »The Patient Information as known when the document was published. May be a reference to a version specific, or containedsourcePatientInfo : Reference [0..1] « Patient »Related identifiers or resources associated with the DocumentReferencerelated : Reference [0..*] « Any »Relationships that this document has with other document references that already existrelatesTo [0..*]The document and format referenced. There may be multiple content element repetitions, each with a different formatcontent [1..*]The clinical context in which the document was preparedcontext [0..1]

XML Template

<DocumentReference xmlns="http://hl7.org/fhir"> doco 
 <!-- from Resource: id, meta, implicitRules, and language -->
 <!-- from DomainResource: text, contained, extension, and modifierExtension -->
 <masterIdentifier><!-- 0..1 Identifier  Master Version Specific Identifier  --></masterIdentifier>
 <identifier><!-- 0..* Identifier  Other identifiers for the document  --></identifier>
 <status value="[code ]"/><!-- 1..1 current | superseded | entered-in-error  -->
 <docStatus value="[code ]"/><!-- 0..1 preliminary | final | amended | entered-in-error  -->
 <type><!-- 0..1 CodeableConcept  Kind of document (LOINC if possible)  --></type>
 <category><!-- 0..* CodeableConcept  Categorization of document  --></category>
 <subject><!-- 0..1 Reference(Device|Group|Patient|Practitioner) Who/what is the subject of the document  --></subject>
 <date value="[instant ]"/><!-- 0..1 When this document reference was created  -->
 <author><!-- 0..* Reference(Device|Organization|Patient|Practitioner|
 PractitionerRole|RelatedPerson) Who and/or what authored the document  --></author>
 <authenticator><!-- 0..1 Reference(Organization|Practitioner|PractitionerRole) Who/what authenticated the document  --></authenticator>
 <custodian><!-- 0..1 Reference(Organization) Organization which maintains the document  --></custodian>
 <relatesTo> <!-- 0..* Relationships to other documents -->
 <code value="[code ]"/><!-- 1..1 replaces | transforms | signs | appends  -->
 <target><!-- 1..1 Reference(DocumentReference) Target of the relationship  --></target>
 </relatesTo>
 <description value="[string ]"/><!-- 0..1 Human-readable description  -->
 <securityLabel><!-- 0..* CodeableConcept  Document security-tags  --></securityLabel>
 <content> <!-- 1..* Document referenced -->
 <attachment><!-- 1..1 Attachment  Where to access the document  --></attachment>
 <format><!-- 0..1 Coding  Format/content rules for the document  --></format>
 </content>
 <context> <!-- 0..1 Clinical context of document -->
 <encounter><!-- 0..* Reference(Encounter|EpisodeOfCare) Context of the document content  --></encounter>
 <event><!-- 0..* CodeableConcept  Main clinical acts documented   --></event>
 <period><!-- 0..1 Period  Time of service that is being documented  --></period>
 <facilityType><!-- 0..1 CodeableConcept  Kind of facility where patient was seen  --></facilityType>
 <practiceSetting><!-- 0..1 CodeableConcept  Additional details about where the content was created (e.g. clinical specialty)  --></practiceSetting>
 <sourcePatientInfo><!-- 0..1 Reference(Patient) Patient demographics from source  --></sourcePatientInfo>
 <related><!-- 0..* Reference(Any) Related identifiers or resources  --></related>
 </context>
</DocumentReference>

JSON Template

{doco 
 "resourceType" : "DocumentReference",
 // from Resource: id, meta, implicitRules, and language
 // from DomainResource: text, contained, extension, and modifierExtension
 "masterIdentifier" : { Identifier  }, // Master Version Specific Identifier 
 "identifier" : [{ Identifier  }], // Other identifiers for the document 
 "status" : "<code >", // R! current | superseded | entered-in-error 
 "docStatus" : "<code >", // preliminary | final | amended | entered-in-error 
 "type" : { CodeableConcept  }, // Kind of document (LOINC if possible) 
 "category" : [{ CodeableConcept  }], // Categorization of document 
 "subject" : { Reference(Device|Group|Patient|Practitioner) }, // Who/what is the subject of the document 
 "date" : "<instant >", // When this document reference was created 
 "author" : [{ Reference(Device|Organization|Patient|Practitioner|
 PractitionerRole|RelatedPerson) }], // Who and/or what authored the document 
 "authenticator" : { Reference(Organization|Practitioner|PractitionerRole) }, // Who/what authenticated the document 
 "custodian" : { Reference(Organization) }, // Organization which maintains the document 
 "relatesTo" : [{ // Relationships to other documents 
 "code" : "<code >", // R! replaces | transforms | signs | appends 
 "target" : { Reference(DocumentReference) } // R! Target of the relationship 
 }],
 "description" : "<string >", // Human-readable description 
 "securityLabel" : [{ CodeableConcept  }], // Document security-tags 
 "content" : [{ // R! Document referenced 
 "attachment" : { Attachment  }, // R! Where to access the document 
 "format" : { Coding  } // Format/content rules for the document 
 }],
 "context" : { // Clinical context of document 
 "encounter" : [{ Reference(Encounter|EpisodeOfCare) }], // Context of the document content 
 "event" : [{ CodeableConcept  }], // Main clinical acts documented  
 "period" : { Period  }, // Time of service that is being documented 
 "facilityType" : { CodeableConcept  }, // Kind of facility where patient was seen 
 "practiceSetting" : { CodeableConcept  }, // Additional details about where the content was created (e.g. clinical specialty) 
 "sourcePatientInfo" : { Reference(Patient) }, // Patient demographics from source 
 "related" : [{ Reference(Any) }] // Related identifiers or resources 
 }
}

Turtle Template

@prefix fhir: <http://hl7.org/fhir/> .doco 
[ a fhir:DocumentReference;
 fhir:nodeRole fhir:treeRoot; # if this is the parser root
 # from Resource: .id, .meta, .implicitRules, and .language
 # from DomainResource: .text, .contained, .extension, and .modifierExtension
 fhir:DocumentReference.masterIdentifier[ Identifier ]; # 0..1 Master Version Specific Identifier
 fhir:DocumentReference.identifier[ Identifier ], ... ; # 0..* Other identifiers for the document
 fhir:DocumentReference.status[ code ]; # 1..1 current | superseded | entered-in-error
 fhir:DocumentReference.docStatus[ code ]; # 0..1 preliminary | final | amended | entered-in-error
 fhir:DocumentReference.type[ CodeableConcept ]; # 0..1 Kind of document (LOINC if possible)
 fhir:DocumentReference.category[ CodeableConcept ], ... ; # 0..* Categorization of document
 fhir:DocumentReference.subject[ Reference(Device|Group|Patient|Practitioner) ]; # 0..1 Who/what is the subject of the document
 fhir:DocumentReference.date[ instant ]; # 0..1 When this document reference was created
 fhir:DocumentReference.author[ Reference(Device|Organization|Patient|Practitioner|PractitionerRole|RelatedPerson) ], ... ; # 0..* Who and/or what authored the document
 fhir:DocumentReference.authenticator[ Reference(Organization|Practitioner|PractitionerRole) ]; # 0..1 Who/what authenticated the document
 fhir:DocumentReference.custodian[ Reference(Organization) ]; # 0..1 Organization which maintains the document
 fhir:DocumentReference.relatesTo[ # 0..* Relationships to other documents
 fhir:DocumentReference.relatesTo.code[ code ]; # 1..1 replaces | transforms | signs | appends
 fhir:DocumentReference.relatesTo.target[ Reference(DocumentReference) ]; # 1..1 Target of the relationship
 ], ...;
 fhir:DocumentReference.description[ string ]; # 0..1 Human-readable description
 fhir:DocumentReference.securityLabel[ CodeableConcept ], ... ; # 0..* Document security-tags
 fhir:DocumentReference.content[ # 1..* Document referenced
 fhir:DocumentReference.content.attachment[ Attachment ]; # 1..1 Where to access the document
 fhir:DocumentReference.content.format[ Coding ]; # 0..1 Format/content rules for the document
 ], ...;
 fhir:DocumentReference.context[ # 0..1 Clinical context of document
 fhir:DocumentReference.context.encounter[ Reference(Encounter|EpisodeOfCare) ], ... ; # 0..* Context of the document content
 fhir:DocumentReference.context.event[ CodeableConcept ], ... ; # 0..* Main clinical acts documented
 fhir:DocumentReference.context.period[ Period ]; # 0..1 Time of service that is being documented
 fhir:DocumentReference.context.facilityType[ CodeableConcept ]; # 0..1 Kind of facility where patient was seen
 fhir:DocumentReference.context.practiceSetting[ CodeableConcept ]; # 0..1 Additional details about where the content was created (e.g. clinical specialty)
 fhir:DocumentReference.context.sourcePatientInfo[ Reference(Patient) ]; # 0..1 Patient demographics from source
 fhir:DocumentReference.context.related[ Reference(Any) ], ... ; # 0..* Related identifiers or resources
 ];
]

Changes since Release 4

DocumentReference
  • No Changes

See the Full Difference for further information

This analysis is available as XML or JSON.

Conversions between R3 and R4

See R3 <--> R4 Conversion Maps (status = 1 test of which 1 fail to execute.)

See the Profiles & Extensions and the alternate definitions: Master Definition XML + JSON, XML Schema/Schematron + JSON Schema, ShEx (for Turtle) + see the extensions & the dependency analysis

2.42.4.1 Terminology Bindings

PathDefinitionTypeReference
DocumentReference.status Required DocumentReferenceStatus
DocumentReference.docStatus Required CompositionStatus
DocumentReference.type Preferred FHIRDocumentTypeCodes
DocumentReference.category Example DocumentClassValueSet
DocumentReference.relatesTo.code Required DocumentRelationshipType
DocumentReference.securityLabel Extensible All Security Labels
DocumentReference.content.format Preferred DocumentReferenceFormatCodeSet
DocumentReference.context.event Example ActCode
DocumentReference.context.facilityType Example FacilityTypeCodeValueSet
DocumentReference.context.practiceSetting Example PracticeSettingCodeValueSet

2.42.5 Implementation Notes

  • The use of the .docStatus codes is discussed in the Composition description
  • The resources maintain one way relationships that point backwards - e.g., the document that replaces one document points towards the document that it replaced. The reverse relationships can be followed by using indexes built from the resources. Typically, this is done using the search parameters described below. Given that documents may have other documents that replace or append them, clients should always check these relationships when accessing documents

2.42.5.1 Generating a Document Reference

A client can ask a server to generate a document reference from a document. The server reads the existing document and generates a matching DocumentReference resource, or returns one it has previously generated. Servers may be able to return or generate document references for the following types of content:

Type Comments
FHIR Documents The uri refers to an existing Document
CDA Document The uri is a reference to a Binary end-point that returns either a CDA document, or some kind of CDA Package that the server knows how to process (e.g., an IHE .zip)
Other The server can be asked to generate a document reference for other kinds of documents. For some of these documents (e.g., PDF documents) a server could only provide a document reference if it already existed or the server had special knowledge of the document.

The server either returns a search result containing a single document reference, or it returns an error. If the URI refers to another server, it is at the discretion of the server whether to retrieve it or return an error.

The operation is initiated by a named query, using _query=generate on the /DocumentReference end-point: 

 GET [service-url]/DocumentReference/?_query=generate&uri=:url&...

The "uri" parameter is a relative or absolute reference to one of the document types described above. Other parameters may be supplied:

Name Meaning
persist Whether to store the document at the document end-point (/Document) or not, once it is generated. Value = true or false (default is for the server to decide).

2.42.6 Search Parameters

Search parameters for this resource. The common parameters also apply. See Searching for more information about searching in REST, messaging, and services.

Name Type Description Expression In Common
authenticator reference Who/what authenticated the document DocumentReference.authenticator
(Practitioner, Organization, PractitionerRole)
author reference Who and/or what authored the document DocumentReference.author
(Practitioner, Organization, Device, Patient, PractitionerRole, RelatedPerson)
category token Categorization of document DocumentReference.category
contenttype token Mime type of the content, with charset etc. DocumentReference.content.attachment.contentType
custodian reference Organization which maintains the document DocumentReference.custodian
(Organization)
date date When this document reference was created DocumentReference.date
description string Human-readable description DocumentReference.description
encounter reference Context of the document content DocumentReference.context.encounter.where(resolve() is Encounter)
(Encounter)
event token Main clinical acts documented DocumentReference.context.event
facility token Kind of facility where patient was seen DocumentReference.context.facilityType
format token Format/content rules for the document DocumentReference.content.format
identifier token Master Version Specific Identifier DocumentReference.masterIdentifier | DocumentReference.identifier
language token Human language of the content (BCP-47) DocumentReference.content.attachment.language
location uri Uri where the data can be found DocumentReference.content.attachment.url
patient reference Who/what is the subject of the document DocumentReference.subject.where(resolve() is Patient)
(Patient)
period date Time of service that is being documented DocumentReference.context.period
related reference Related identifiers or resources DocumentReference.context.related
(Any)
relatesto reference Target of the relationship DocumentReference.relatesTo.target
(DocumentReference)
relation token replaces | transforms | signs | appends DocumentReference.relatesTo.code
relationship composite Combination of relation and relatesTo On DocumentReference.relatesTo:
relatesto: code
relation: target
security-label token Document security-tags DocumentReference.securityLabel
setting token Additional details about where the content was created (e.g. clinical specialty) DocumentReference.context.practiceSetting
status token current | superseded | entered-in-error DocumentReference.status
subject reference Who/what is the subject of the document DocumentReference.subject
(Practitioner, Group, Device, Patient)
type token Kind of document (LOINC if possible) DocumentReference.type

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