Path | Short | Definition | Comments |
---|---|---|---|
A reference to a document | 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. | Usually, this is used for documents other than those defined by FHIR. | |
masterIdentifier | Master Version Specific Identifier | 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 document. | CDA Document Id extension and root. |
identifier | Other identifiers for the document | Other identifiers associated with the document, including version independent identifiers. | |
status | current | superseded | entered-in-error | The status of this document reference. | 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. |
docStatus | preliminary | final | appended | amended | entered-in-error | The status of the underlying document. | The document that is pointed to might be in various lifecycle states. |
type | Kind of document (LOINC if possible) | 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. | 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. |
category | Categorization of document | 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. | 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. |
subject | Who/what is the subject of the document | 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). | |
date | When this document reference was created | When the document reference was created. | Referencing/indexing time is used for tracking, organizing versions and searching. |
author | Who and/or what authored the document | Identifies who is responsible for adding the information to the document. | Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). |
authenticator | Who/what authenticated the document | Which person or organization authenticates that this document is valid. | Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator. |
custodian | Organization which maintains the document | Identifies the organization or group who is responsible for ongoing maintenance of and access to the document. | 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. |
relatesTo | Relationships to other documents | Relationships that this document has with other document references that already exist. | This element is labeled as a modifier because documents that append to other documents are incomplete on their own. |
relatesTo.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
relatesTo.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
relatesTo.code | replaces | transforms | signs | appends | The type of relationship that this document has with anther document. | If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. |
relatesTo.target | Target of the relationship | The target document of this relationship. | |
description | Human-readable description | Human-readable description of the source document. | What the document is about, a terse summary of the document. |
securityLabel | Document security-tags | 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. | 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. |
content | Document referenced | The document and format referenced. There may be multiple content element repetitions, each with a different format. | |
content.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
content.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
content.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
content.attachment | Where to access the document | The document or URL of the document along with critical metadata to prove content has integrity. | |
content.format | Format/content rules for the document | An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. | Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. |
context | Clinical context of document | The clinical context in which the document was prepared. | These values are primarily added to help with searching for interesting/relevant documents. |
context.id | Unique id for inter-element referencing | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. | |
context.extension | Additional content defined by implementations | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
context.modifierExtension | Extensions that cannot be ignored even if unrecognized | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
context.encounter | Context of the document content | Describes the clinical encounter or type of care that the document content is associated with. | |
context.event | Main clinical acts documented | 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. | 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. |
context.period | Time of service that is being documented | The time period over which the service that is described by the document was provided. | |
context.facilityType | Kind of facility where patient was seen | The kind of facility where the patient was seen. | |
context.practiceSetting | Additional details about where the content was created (e.g. clinical specialty) | This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. | 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. |
context.sourcePatientInfo | Patient demographics from source | The Patient Information as known when the document was published. May be a reference to a version specific, or contained. | |
context.related | Related identifiers or resources | Related identifiers or resources associated with the DocumentReference. | May be identifiers or resources that caused the DocumentReference or referenced Document to be created. |
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:
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.
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). |
authenticator | Who/what authenticated the document | DocumentReference.authenticator |
author | Who and/or what authored the document | DocumentReference.author |
category | Categorization of document | DocumentReference.category |
contenttype | Mime type of the content, with charset etc. | DocumentReference.content.attachment.contentType |
custodian | Organization which maintains the document | DocumentReference.custodian |
date | When this document reference was created | DocumentReference.date |
description | Human-readable description | DocumentReference.description |
event | Main clinical acts documented | DocumentReference.context.event |
facility | Kind of facility where patient was seen | DocumentReference.context.facilityType |
format | Format/content rules for the document | DocumentReference.content.format |
language | Human language of the content (BCP-47) | DocumentReference.content.attachment.language |
location | Uri where the data can be found | DocumentReference.content.attachment.url |
period | Time of service that is being documented | DocumentReference.context.period |
related | Related identifiers or resources | DocumentReference.context.related |
relatesto | Target of the relationship | DocumentReference.relatesTo.target |
relation | replaces | transforms | signs | appends | DocumentReference.relatesTo.code |
security-label | Document security-tags | DocumentReference.securityLabel |
setting | Additional details about where the content was created (e.g. clinical specialty) | DocumentReference.context.practiceSetting |
status | current | superseded | entered-in-error | DocumentReference.status |
subject | Who/what is the subject of the document | DocumentReference.subject |
relationship | Combination of relation and relatesTo | DocumentReference.relatesTo |