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Resource DocumentReference - Content 6.4

A reference to a document.

The resource name as it appears in a RESTful URL is [root]/documentreference/

A document reference resource is used to describe a document that is made available to a healthcare system. A document is some sequence of bytes that is identifiable, establishes it's own context (e.g. what subject, author etc), can be displayed to the user, and has defined update management. The document resource can be used with any document format that has a recognised mime type, and that conforms to this definition.

Typically, Document Reference Resources are used in document indexing systems, such as IHE XDS (see the XDS specific profile), and are used to refer to:

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 other 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 a v2 message query, though the way each of these service calls works must be specified in some external stanard or other documentation.

Resource Content 6.4.1

DocumentReference (Resource)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 1..1Other identifiers associated with the recordidentifier : Identifier 0..*Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (I.e. 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 : Resource(Patient|Practitioner|Group|Device) 1..1Specifies the particular kind of document (e.g. Patient Summary, Discharge Summary, Prescription, etc.)type : CodeableConcept 1..1 <<Type of a clinical documentDocumentType>>More detailed information about the document typesubtype : CodeableConcept 0..1 <<SubType of a clinical documentDocumentSubType>>Identifies who is responsible for adding the information to the documentauthor : Resource(Practitioner|Device) 1..*Identifies the organization or group who is responsible for ongoing maintenance of and access to the documentcustodian : Resource(Organization) 0..1Which person or organization authenticates that this document is validauthenticator : Resource(Practitioner|Organization) 0..1When the document was createdcreated : dateTime 0..1When the document reference was createdindexed : instant 1..1The status of this document reference (this element modifies the meaning of other elements)status : code 1..1 <<The status of the document referenceDocumentReferenceStatus>>The status of the underlying documentdocStatus : CodeableConcept 0..1 <<Status of the underlying documentReferredDocumentStatus>>If this document replaces another (this element modifies the meaning of other elements)supercedes : Resource(DocumentReference) 0..1Human Readable description of the source document. This is sometimes known as the "title"description : string 0..1A code specifying the level of confidentiality of the XDS Document (this element modifies the meaning of other elements)confidentiality : CodeableConcept 0..1 <<Codes specifying the level of confidentiality of the XDS DocumentDocumentConfidentiality>>The primary language in which the source document is writtenprimaryLanguage : code 0..1 <<A human languageLanguage>>The mime type of the source documentmimeType : code 1..1 <<The mime type of an attachmentMimeType>>The format of the document. This is used when the mimeType of the document does not provide enough differentiating information (typically, when the mime type of the document is text/xml)format : CodeableConcept 0..1 <<Format of the source documentDocumentFormat>>The size of the source document this reference refers to in bytessize : integer 0..1A hash of the source document to ensure that changes have not occurredhash : string 0..1A url at which the document can be accessedlocation : uri 0..1ServiceThe type of the service that can be used to access the documentstype : CodeableConcept 1..1 <<Document Reference Service TypeDocumentServiceType>>Where the service end-point is locatedaddress : string 0..1ParameterThe name of a parametername : string 1..1The value of the named parametervalue : string 0..1ContextThe type of clinical context, such as a kind of surgery, or a kind of speciality, or a clinical typecode : CodeableConcept 0..* <<This list of codes represents the main clinical acts being documentedDocumentEventCode>>The time period of the patient's care that is described by the documentperiod : Period 0..1The kind of facility where the patient was seenfacilityType : CodeableConcept 0..1 <<XDS Facility TypeDocumentFacilityType>>A list of named parameters that is used in the service callparameter0..*A description of a service call that can be used to retrieve the documentservice0..1The clinical context in which the document was preparedcontext0..1 
<DocumentReference xmlns="http://hl7.org/fhir">
 <!-- from Resource: extension, narrative, and contained -->
 <masterIdentifier><!-- 1..1 Identifier Master Version Specific Identifier --></masterIdentifier>
 <identifier><!-- 0..* Identifier Other identifiers for the document --></identifier>
 <subject><!-- 1..1 Resource(Patient|Practitioner|Group|Device) The subject of the document --></subject>
 <type><!-- 1..1 CodeableConcept What kind of document this is (LOINC if possible) --></type>
 <subtype><!-- 0..1 CodeableConcept More detail about the document type --></subtype>
 <author><!-- 1..* Resource(Practitioner|Device) Who/what authored the document --></author>
 <custodian><!-- 0..1 Resource(Organization) Org which maintains the document --></custodian>
 <authenticator><!-- 0..1 Resource(Practitioner|Organization) Who authenticated the document --></authenticator>
 <created value="[dateTime]"/><!-- 0..1 Document creation time -->
 <indexed value="[instant]"/><!-- 1..1 When this document reference created -->
 <status value="[code]"/><!-- 1..1 current | superseded | error -->
 <docStatus><!-- 0..1 CodeableConcept Status of the underlying document --></docStatus>
 <supercedes><!-- 0..1 Resource(DocumentReference) If this document replaces another --></supercedes>
 <description value="[string]"/><!-- 0..1 Human Readable description (title) -->
 <confidentiality><!-- 0..1 CodeableConcept Sensitivity of source document --></confidentiality>
 <primaryLanguage value="[code]"/><!-- 0..1 Primary language of the document -->
 <mimeType value="[code]"/><!-- 1..1 Mime type of the document -->
 <format><!-- 0..1 CodeableConcept Format of the document --></format>
 <size value="[integer]"/><!-- 0..1 Size of the document in bytes -->
 <hash value="[string]"/><!-- 0..1 HexBinary representation of SHA1 -->
 <location value="[uri]"/><!-- 0..1 Where to access the document -->
 <service>  <!-- 0..1 If access is not fully described by location -->
  <type><!-- 1..1 CodeableConcept Type of service (i.e. XDS.b) --></type>
  <address value="[string]"/><!-- 0..1 Where service is located (usually a URL) -->
  <parameter>  <!-- 0..* Service call parameters -->
   <name value="[string]"/><!-- 1..1 Name of parameter -->
   <value value="[string]"/><!-- 0..1 Parameter value -->
  </parameter>
 </service>
 <context>  <!-- 0..1 Clinical context of document -->
  <code><!-- 0..* CodeableConcept Type of context (i.e. type of event) --></code>
  <period><!-- 0..1 Period Time described by the document --></period>
  <facilityType><!-- 0..1 CodeableConcept Kind of facility where patient was seen --></facilityType>
 </context>
</DocumentReference>

Alternate definitions: Schema/Schematron, Resource Profile

Terminology Bindings 6.4.1.1

PathDefinitionTypeReference
DocumentReference.type Type of a clinical documentIncompletehttp://hl7.org/fhir/vs/doc-codes
DocumentReference.subtype SubType of a clinical documentExamplehttp://hl7.org/fhir/vs/xds-typecodes
DocumentReference.status The status of the document referenceFixedhttp://hl7.org/fhir/document-reference-status
DocumentReference.docStatus Status of the underlying documentIncompletehttp://hl7.org/fhir/vs/document-status
DocumentReference.confidentiality Codes specifying the level of confidentiality of the XDS DocumentExamplehttp://hl7.org/fhir/vs/doc-confidentiality
DocumentReference.primaryLanguage A human languageIncompleteIETF language tag
DocumentReference.mimeType The mime type of an attachmentIncompleteBCP 13 (RFCs 2045, 2046, 2047, 4288, 4289 and 2049)
DocumentReference.format Format of the source documentExamplehttp://hl7.org/fhir/vs/xds-formatcodes
DocumentReference.service.type Document Reference Service TypeIncompletehttp://hl7.org/fhir/vs/documentreference-service-types
DocumentReference.context.code This list of codes represents the main clinical acts being documentedExamplehttp://hl7.org/fhir/vs/doc-event-code
DocumentReference.context.facilityType XDS Facility TypeExamplehttp://hl7.org/fhir/vs/xds-facilitycodes

Constraints 6.4.1.2

Search Parameters 6.4.2

Search Parameters for RESTful searches. The standard parameters also apply. See Searching for more information.

Name / TypeDescriptionPaths
_id : tokenThe logical resource id associated with the resource (must be supported by all servers)
authenticator : referenceWho authenticated the documentDocumentReference.authenticator
author : referenceWho/what authored the documentDocumentReference.author
confidentiality : tokenSensitivity of source documentDocumentReference.confidentiality
created : dateDocument creation timeDocumentReference.created
custodian : referenceOrg which maintains the documentDocumentReference.custodian
description : textHuman Readable description (title)DocumentReference.description
event : tokenType of context (i.e. type of event)DocumentReference.context.code
facility : tokenKind of facility where patient was seenDocumentReference.context.facilityType
format : tokenFormat of the documentDocumentReference.format
identifier : tokenOther identifiers for the documentDocumentReference.identifier
indexed : dateWhen this document reference createdDocumentReference.indexed
language : tokenPrimary language of the documentDocumentReference.primaryLanguage
location : stringWhere to access the documentDocumentReference.location
period : dateTime described by the documentDocumentReference.context.period
size : integerSize of the document in bytesDocumentReference.size
status : tokencurrent | superseded | errorDocumentReference.status
subject : referenceThe subject of the documentDocumentReference.subject
subtype : tokenMore detail about the document typeDocumentReference.subtype
supersedes : referenceIf this document replaces anotherDocumentReference.supercedes
type : tokenWhat kind of document this is (LOINC if possible)DocumentReference.type