Release 4 5 Draft Ballot
This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU ). This is the current published version in it's permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Structured Documents Orders and Observations Work Group Maturity Level : 3   Trial Use Security Category : Not Classified Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Detailed Descriptions for the elements in the DocumentReference resource.

Comments CDA Document Id extension and root.
DocumentReference
Element Id DocumentReference
Definition

A reference to a document of any kind for any purpose. Provides metadata about the document so that While the document can be discovered and managed. The scope of term “document” implies a document is more narrow focus, for this resource this "document" encompasses any seralized serialized object with a mime-type, so it includes formal patient centric patient-centric documents (CDA), cliical clinical notes, scanned paper, and non-patient specific documents like policy text. text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.

Cardinality 0..*
Type DomainResource
Summary false
Comments

Usually, this is used for documents other than those defined by FHIR.

DocumentReference.masterIdentifier DocumentReference.identifier
Element Id DocumentReference.masterIdentifier DocumentReference.identifier
Definition

Document identifier as assigned by the source of Other identifiers associated with the document. This identifier is specific to this document, including version of the document. independent identifiers.

Note This unique is a business identifier, not a resource identifier may be used elsewhere to identify this version of the document. (see discussion )
Cardinality 0..1 0..*
Type Identifier
Requirements The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.). Summary true
DocumentReference.identifier DocumentReference.basedOn
Element Id DocumentReference.identifier DocumentReference.basedOn
Definition

Other identifiers associated with A procedure that is fulfilled in whole or in part by the document, including version independent identifiers. creation of this media.

Note This is a business identifier, not a resource identifier (see discussion ) Cardinality 0..*
Type Identifier Reference ( ServiceRequest | CarePlan )
Patterns Reference(ServiceRequest,CarePlan): Common patterns = Request
Requirements

Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

Alternate Names fulfills
Summary true false
DocumentReference.status
Element Id DocumentReference.status
Definition

The status of this document reference.

Cardinality 1..1
Terminology Binding DocumentReferenceStatus ( Required )
Type code
Is Modifier true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)
Summary true
Comments

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

DocumentReference.docStatus
Element Id DocumentReference.docStatus
Definition

The status of the underlying document.

Cardinality 0..1
Terminology Binding CompositionStatus ( Required )
Type code
Summary true
Comments

The document that is pointed to might be in various lifecycle states.

DocumentReference.type
Element Id DocumentReference.type
Definition

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 referenced.

Cardinality 0..1
Terminology Binding Document Type Value Set ( Preferred ) DocumentC80Type :
Type CodeableConcept
Summary true
Comments

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

DocumentReference.category
Element Id DocumentReference.category
Definition

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.type.

Cardinality 0..*
Terminology Binding Document Class Value Set ( Example )
Type CodeableConcept
Alternate Names claxs class
Summary true
Comments

Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

DocumentReference.subject
Element Id DocumentReference.subject
Definition

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).

Cardinality 0..1
Type Reference ( Patient | Practitioner | Group | Device | PractitionerRole | Specimen | Organization | Location )
Patterns Reference(Patient,Practitioner,Group,Device,PractitionerRole,Specimen,Organization,Location): No common pattern
Summary true
DocumentReference.encounter
Element Id DocumentReference.encounter
Definition

Describes the clinical encounter or type of care that the document content is associated with.

Cardinality 0..*
Type Reference ( Encounter )
Summary false
DocumentReference.event
Element Id DocumentReference.event
Definition

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" act.

Cardinality 0..*
Terminology Binding v3 Code System ActCode ( Example )
Type CodeableConcept
Summary false
Comments

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

DocumentReference.facilityType
Element Id DocumentReference.facilityType
Definition

The kind of facility where the patient was seen.

Cardinality 0..1
Terminology Binding DocumentC80FacilityType :
Type CodeableConcept
Summary false
DocumentReference.practiceSetting
Element Id DocumentReference.practiceSetting
Definition

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Cardinality 0..1
Terminology Binding DocumentC80PracticeSetting :
Type CodeableConcept
Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Summary false
Comments

This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

DocumentReference.period
Element Id DocumentReference.period
Definition

The time period over which the service that is described by the document was provided.

Cardinality 0..1
Type Period
Summary true
DocumentReference.date
Element Id DocumentReference.date
Definition

When the document reference was created.

Cardinality 0..1
Type instant
Alternate Names indexed
Summary true
Comments

Referencing/indexing time is used for tracking, organizing versions and searching.

DocumentReference.author
Element Id DocumentReference.author
Definition

Identifies who is responsible for adding the information to the document.

Cardinality 0..*
Type Reference ( Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson | CareTeam )
Patterns Reference(Practitioner,PractitionerRole,Organization,Device,Patient,RelatedPerson,CareTeam): Common patterns = Participant
Summary true
Comments

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

DocumentReference.authenticator DocumentReference.attester
Element Id DocumentReference.authenticator DocumentReference.attester
Definition

Which person or organization authenticates that this document is valid. A participant who has attested to the accuracy of the composition/document.

Cardinality 0..*
Requirements

Identifies responsibility for the accuracy of the composition content.

Summary false
Comments

Only list each attester once.

DocumentReference.attester.mode
Element Id DocumentReference.attester.mode
Definition

The type of attestation the authenticator offers.

Cardinality 1..1
Terminology Binding DocumentAttestationMode ( Required )
Type code
Requirements

Indicates the level of authority of the attestation.

Summary false
DocumentReference.attester.time
Element Id DocumentReference.attester.time
Definition

When the composition was attested by the party.

Cardinality 0..1
Type dateTime
Requirements

Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).

Summary false
DocumentReference.attester.party
Element Id DocumentReference.attester.party
Definition

Who attested the composition in the specified way.

Cardinality 0..1
Type Reference ( Patient | RelatedPerson | Practitioner | PractitionerRole | Organization )
Comments Patterns Reference(Patient,RelatedPerson,Practitioner,PractitionerRole,Organization): Common patterns = Participant
Requirements

Represents a participant within the author institution Identifies who has legally authenticated or attested taken on the document. Legal authentication implies that a document has been signed manually or electronically by responsibility for accuracy of the legal Authenticator. composition content.

Summary false
DocumentReference.custodian
Element Id DocumentReference.custodian
Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Cardinality 0..1
Type Reference ( Organization )
Summary false
Comments

Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

DocumentReference.relatesTo
Element Id DocumentReference.relatesTo
Definition

Relationships that this document has with other document references that already exist.

Cardinality 0..*
Summary true
Comments

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

DocumentReference.relatesTo.code
Element Id DocumentReference.relatesTo.code
Definition

The type of relationship that this document has with anther document.

Cardinality 1..1
Terminology Binding DocumentRelationshipType ( Required )
Type code
Summary true
Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

DocumentReference.relatesTo.target
Element Id DocumentReference.relatesTo.target
Definition

The target document of this relationship.

Cardinality 1..1
Type Reference ( DocumentReference )
Summary true
DocumentReference.description
Element Id DocumentReference.description
Definition

Human-readable description of the source document.

Cardinality 0..1
Type string markdown
Requirements

Helps humans to assess whether the document is of interest.

Summary true
Comments

What the document is about, a terse summary of the document.

DocumentReference.securityLabel
Element Id DocumentReference.securityLabel
Definition

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 to.

Cardinality 0..*
Terminology Binding SecurityLabels ( Extensible )
Type CodeableConcept
Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Summary true
Comments

The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

DocumentReference.content
Element Id DocumentReference.content
Definition

The document and format referenced. There may be If there are multiple content element repetitions, each with a these must all represent the same document in different format. format, or attachment metadata.

Cardinality 1..*
Requirements

Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

Summary true
Comments

content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

DocumentReference.content.attachment
Element Id DocumentReference.content.attachment
Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Cardinality 1..1
Type Attachment
Summary true
DocumentReference.content.format
Element Id DocumentReference.content.format
Definition

An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Cardinality 0..1
Terminology Binding DocumentReference Format Code Set ( Preferred )
Type Coding
Summary true
Comments

Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.

DocumentReference.context DocumentReference.content.identifier
Element Id DocumentReference.context DocumentReference.content.identifier
Definition

The clinical context in which Document identifier as assigned by the document was prepared. Cardinality 0..1 Summary true Comments These values are primarily added source of the document. This identifier is specific to help with searching for interesting/relevant documents. DocumentReference.context.encounter Element Id DocumentReference.context.encounter Definition Describes this version of the clinical encounter or type document. This unique identifier may be used elsewhere to identify this version of care that the document content is associated with. document.

Cardinality 0..* Type Reference ( Encounter | EpisodeOfCare ) DocumentReference.context.event Element Id DocumentReference.context.event Definition Note 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 business identifier, not a "History and Physical" act. resource identifier (see discussion )
Cardinality 0..* Terminology Binding v3 Code System ActCode ( Example ) 0..1
Type CodeableConcept Identifier
Comments Requirements

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" The structure and the procedure was a "colonoscopy". If one or more event codes are included, they format of this Id shall not conflict be consistent with the values inherent in specification corresponding to the class or type elements as such formatCode attribute. (e.g. for a conflict would create DICOM standard document a 64-character numeric UID, for an ambiguous situation. DocumentReference.context.period Element Id DocumentReference.context.period Definition The time period over which the service that is described by HL7 CDA format a serialization of the document was provided. Cardinality 0..1 Type Period Summary true DocumentReference.context.facilityType Element CDA Document Id DocumentReference.context.facilityType Definition The kind of facility extension and root in the form "oid^extension", where OID is a 64 digits max, and the patient was seen. Cardinality 0..1 Terminology Binding Facility Type Code Value Set ( Example ) Type CodeableConcept DocumentReference.context.practiceSetting Element Id DocumentReference.context.practiceSetting Definition This property may convey specifics about is a 16 UTF-8 char max. If the practice setting where OID is coded without the content was created, often reflecting extension then the clinical specialty. '^' character shall not be included.).

Cardinality 0..1 Terminology Binding Practice Setting Code Value Set ( Example ) Type CodeableConcept Summary Requirements This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. true
Comments

This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. CDA Document Id extension and root.

DocumentReference.context.sourcePatientInfo DocumentReference.sourcePatientInfo
Element Id DocumentReference.context.sourcePatientInfo DocumentReference.sourcePatientInfo
Definition

The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Cardinality 0..1
Type Reference ( Patient )
Summary false
DocumentReference.context.related DocumentReference.related
Element Id DocumentReference.context.related DocumentReference.related
Definition

Related identifiers or resources associated with the DocumentReference.

Cardinality 0..*
Type Reference ( Any )
Summary false
Comments

May be identifiers or resources that caused the DocumentReference or referenced Document to be created.