Release 4
FoundationThis page is part of the FHIR Specification (v4.0.1: R4 - MixedNormative andSTU) in it's permanent home (it will always be available at this URL). The current version which supercedes this version is5.0.0. For a full list of available versions, see theDirectory of published versions
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| 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.
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 asIHE XDS,such as profiled inIHE Mobile access to Health Documents.
DocumentReference is metadata describing a document such as:
documents in FHIR systems, Scanned Paper, and digital records of faxesFHIR defines both adocument 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 specialFHIR 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 anHL7 v2 message query - though the way each of these service calls works must be specified in some external standard or other documentation.
ADocumentReference 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 documentreference. 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 byother actors. In theDocumentReference resource, themetacontent refers to the provenance of the reference itself, while the content described below concernsthe document it references. Like all resources, there is overlap between the information in the resource directly, and in the generalProvenance resource. This is discussed aspart of the description of the Provenance resource.
This resource is referenced byAdverseEvent,CarePlan,Communication,CommunicationRequest,Consent,Contract,DeviceRequest,DeviceUseStatement, itself,FamilyMemberHistory,GuidanceResponse,ImagingStudy,MedicationKnowledge,MedicinalProduct,Observation,Procedure,RequestGroup,RiskAssessment,ServiceRequest,SubstanceReferenceInformation,SubstanceSpecification andSupplyRequest
Structure
UML Diagram (Legend)
XML Template
<DocumentReference xmlns="http://hl7.org/fhir"><!-- fromResource:id,meta,implicitRules, andlanguage --> <!-- fromDomainResource:text,contained,extension, andmodifierExtension --> <masterIdentifier><!--0..1IdentifierMaster Version Specific Identifier --></masterIdentifier> <identifier><!--0..*IdentifierOther identifiers for the document --></identifier> <status value="[code]"/><!--1..1current | superseded | entered-in-error --> <docStatus value="[code]"/><!--0..1preliminary | final | amended | entered-in-error --> <type><!--0..1CodeableConceptKind of document (LOINC if possible) --></type> <category><!--0..*CodeableConceptCategorization of document --></category> <subject><!--0..1Reference(Patient|Practitioner|Group|Device)Who/what is the subject of the document --></subject> <date value="[instant]"/><!--0..1When this document reference was created --> <author><!--0..*Reference(Practitioner|PractitionerRole|Organization|Device|Patient|RelatedPerson)Who and/or what authored the document --></author> <authenticator><!--0..1Reference(Practitioner|PractitionerRole|Organization)Who/what authenticated the document --></authenticator> <custodian><!--0..1Reference(Organization)Organization which maintains the document --></custodian> <relatesTo><!--0..* Relationships to other documents --> <code value="[code]"/><!--1..1replaces | transforms | signs | appends --> <target><!--1..1Reference(DocumentReference)Target of the relationship --></target> </relatesTo> <description value="[string]"/><!--0..1Human-readable description --> <securityLabel><!--0..*CodeableConceptDocument security-tags --></securityLabel> <content><!--1..* Document referenced --> <attachment><!--1..1AttachmentWhere to access the document --></attachment> <format><!--0..1CodingFormat/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..*CodeableConceptMain clinical acts documented --></event> <period><!--0..1PeriodTime of service that is being documented --></period> <facilityType><!--0..1CodeableConceptKind of facility where patient was seen --></facilityType> <practiceSetting><!--0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty) --></practiceSetting> <sourcePatientInfo><!--0..1Reference(Patient)Patient demographics from source --></sourcePatientInfo> <related><!--0..*Reference(Any)Related identifiers or resources --></related> </context></DocumentReference>
JSON Template
{ "resourceType" : "DocumentReference", // fromResource:id,meta,implicitRules, andlanguage // fromDomainResource:text,contained,extension, andmodifierExtension "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(Patient|Practitioner|Group|Device) },//Who/what is the subject of the document "date" : "<instant>",//When this document reference was created "author" : [{Reference(Practitioner|PractitionerRole|Organization|Device|Patient|RelatedPerson) }],//Who and/or what authored the document "authenticator" : {Reference(Practitioner|PractitionerRole|Organization) },//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/> .
Changes since R3
| DocumentReference | |
| DocumentReference.status |
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| DocumentReference.docStatus |
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| DocumentReference.type |
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| DocumentReference.category |
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| DocumentReference.date |
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| DocumentReference.author |
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| DocumentReference.authenticator |
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| DocumentReference.relatesTo |
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| DocumentReference.relatesTo.code |
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| DocumentReference.context.encounter |
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| DocumentReference.context.related |
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| DocumentReference.created |
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| DocumentReference.indexed |
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| DocumentReference.context.related.identifier |
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| DocumentReference.context.related.ref |
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See theFull Difference for further information
This analysis is available asXML orJSON.
SeeR3 <--> R4 Conversion Maps (status = 1 testof which 1 fail to execute.)
Structure
UML Diagram (Legend)
XML Template
<DocumentReference xmlns="http://hl7.org/fhir">
JSON Template
{ "resourceType" : "DocumentReference", // fromResource:id,meta,implicitRules, andlanguage // fromDomainResource:text,contained,extension, andmodifierExtension "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(Patient|Practitioner|Group|Device) },//Who/what is the subject of the document "date" : "<instant>",//When this document reference was created "author" : [{Reference(Practitioner|PractitionerRole|Organization|Device|Patient|RelatedPerson) }],//Who and/or what authored the document "authenticator" : {Reference(Practitioner|PractitionerRole|Organization) },//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/> .
Changes since Release 3
| DocumentReference | |
| DocumentReference.status |
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| DocumentReference.docStatus |
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| DocumentReference.type |
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| DocumentReference.category |
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| DocumentReference.date |
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| DocumentReference.author |
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| DocumentReference.authenticator |
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| DocumentReference.relatesTo |
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| DocumentReference.relatesTo.code |
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| DocumentReference.context.encounter |
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| DocumentReference.context.related |
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| DocumentReference.created |
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| DocumentReference.indexed |
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| DocumentReference.context.related.identifier |
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| DocumentReference.context.related.ref |
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See theFull Difference for further information
This analysis is available asXML orJSON.
SeeR3 <--> R4 Conversion Maps (status = 1 testof which 1 fail to execute.)
See theProfiles & Extensions and the alternate definitions:Master DefinitionXML +JSON,XMLSchema/Schematron +JSONSchema,ShEx (forTurtle) +see the extensions & thedependency analysis
| Path | Definition | Type | Reference |
|---|---|---|---|
| DocumentReference.status | The status of the document reference. | Required | DocumentReferenceStatus |
| DocumentReference.docStatus | Status of the underlying document. | Required | CompositionStatus |
| DocumentReference.type | Precise type of clinical document. | Preferred | DocumentTypeValueSet |
| DocumentReference.category | High-level kind of a clinical document at a macro level. | Example | DocumentClassValueSet |
| DocumentReference.relatesTo.code | The type of relationship between documents. | Required | DocumentRelationshipType |
| DocumentReference.securityLabel | Security Labels from the Healthcare Privacy and Security Classification System. | Extensible | All Security Labels |
| DocumentReference.content.format | Document Format Codes. | Preferred | DocumentReferenceFormatCodeSet |
| DocumentReference.context.event | This list of codes represents the main clinical acts being documented. | Example | v3.ActCode |
| DocumentReference.context.facilityType | XDS Facility Type. | Example | FacilityTypeCodeValueSet |
| DocumentReference.context.practiceSetting | Additional details about where the content was created (e.g. clinical specialty). | Example | PracticeSettingCodeValueSet |
A client can ask a server to generate a document reference from a document.The server reads the existing document and generates a matching DocumentReferenceresource, 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 aBinary 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 /DocumentReferenceend-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). |
Search parameters for this resource. Thecommon parameters also apply. SeeSearching 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 (EpisodeOfCare,Encounter) | 12 Resources |
| 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 | 30 Resources |
| 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) | 33 Resources |
| 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 | 5 Resources |
®© HL7.org 2011+. FHIR Release 4 (Technical Correction #1) (v4.0.1) generated on Fri, Nov 1, 2019 09:35+1100.QA Page
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