DocumentReference - FHIR Resource (stu3)


Resource Attributes

AttributeField is listTypeDescription
authenticatorfalseReference Who/what authenticated the document
authortrueReference "author" : [{ Reference(Practitioner|Organization|Device|Patient|
classfalseCodeableConcept Categorization of document
contenttrueData Type Document referenced
contextfalseData Type Clinical context of document
createdfalsedateTime Document creation time
custodianfalseReference Organization which maintains the document
descriptionfalsestring Human-readable description (title)
docStatusfalsecode preliminary | final | appended | amended | entered-in-error
identifiertrueIdentifier Other identifiers for the document
indexedfalseinstant When this document reference was created
masterIdentifierfalseIdentifier Master Version Specific Identifier
relatesTotrueData Type Relationships to other documents
securityLabeltrueCodeableConcept Document security-tags
statusfalsecode current | superseded | entered-in-error
subjectfalseReference Who/what is the subject of the document
typefalseCodeableConcept Kind of document (LOINC if possible)

DocumentReference Example

{
  "status": "current",
  "content": [
    {
      "attachment": {
        "url": "http://example.org/xds/mhd/Binary/07a6483f-732b-461e-86b6-edb665c45510",
        "hash": "2jmj7l5rSw0yVb/vlWAYkK/YBwk=",
        "contentType": "application/hl7-v3+xml",
        "language": "en-US",
        "size": 3654
      },
      "format": {
        "code": "urn:ihe:pcc:handp:2008",
        "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
        "display": "History and Physical Specification"
      }
    }
  ],
  "author": [
    {
      "reference": "Practitioner/xcda1"
    },
    {
      "reference": "#a2"
    }
  ],
  "masterIdentifier": {
    "system": "urn:ietf:rfc:3986",
    "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7"
  },
  "resourceType": "DocumentReference",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><p><b>Generated Narrative with Details</b></p><p><b>id</b>: example</p><p><b>contained</b>: </p><p><b>masterIdentifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7</p><p><b>identifier</b>: urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234</p><p><b>status</b>: current</p><p><b>docStatus</b>: preliminary</p><p><b>type</b>: Outpatient Note <span>(Details : {LOINC code '34108-1' = 'Outpatient Note', given as 'Outpatient Note'})</span></p><p><b>class</b>: History and Physical <span>(Details : {http://ihe.net/xds/connectathon/classCodes code 'History and Physical' = 'History and Physical', given as 'History and Physical'})</span></p><p><b>subject</b>: <a>Patient/xcda</a></p><p><b>created</b>: 24/12/2005 9:35:00 AM</p><p><b>indexed</b>: 24/12/2005 9:43:41 AM</p><p><b>author</b>: <a>Practitioner/xcda1</a>, id: a2; Gerald Smitty </p><p><b>authenticator</b>: <a>Organization/f001</a></p><p><b>custodian</b>: <a>Organization/f001</a></p><h3>RelatesTos</h3><table><tr><td>-</td><td><b>Code</b></td><td><b>Target</b></td></tr><tr><td>*</td><td>appends</td><td><a>DocumentReference/example</a></td></tr></table><p><b>description</b>: Physical</p><p><b>securityLabel</b>: very restricted <span>(Details : {http://hl7.org/fhir/v3/Confidentiality code 'V' = 'very restricted', given as 'very restricted'})</span></p><h3>Contents</h3><table><tr><td>-</td><td><b>Attachment</b></td><td><b>Format</b></td></tr><tr><td>*</td><td/><td>History and Physical Specification (Details: urn:oid:1.3.6.1.4.1.19376.1.2.3 code urn:ihe:pcc:handp:2008 = 'urn:ihe:pcc:handp:2008', stated as 'History and Physical Specification')</td></tr></table><blockquote><p><b>context</b></p><p><b>encounter</b>: <a>Encounter/xcda</a></p><p><b>event</b>: Arm <span>(Details : {http://ihe.net/xds/connectathon/eventCodes code 'T-D8200' = 'T-D8200', given as 'Arm'})</span></p><p><b>period</b>: 23/12/2004 8:00:00 AM --&gt; 23/12/2004 8:01:00 AM</p><p><b>facilityType</b>: Outpatient <span>(Details : {http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes code 'Outpatient' = 'Outpatient', given as 'Outpatient'})</span></p><p><b>practiceSetting</b>: General Medicine <span>(Details : {http://www.ihe.net/xds/connectathon/practiceSettingCodes code 'General Medicine' = 'General Medicine', given as 'General Medicine'})</span></p><p><b>sourcePatientInfo</b>: <a>Patient/xcda</a></p><h3>Relateds</h3><table><tr><td>-</td><td><b>Identifier</b></td><td><b>Ref</b></td></tr><tr><td>*</td><td>urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345</td><td><a>Patient/xcda</a></td></tr></table></blockquote></div>"
  },
  "description": "Physical",
  "created": "2005-12-24T09:35:00+11:00",
  "relatesTo": [
    {
      "code": "appends",
      "target": {
        "reference": "DocumentReference/example"
      }
    }
  ],
  "class": {
    "coding": [
      {
        "code": "History and Physical",
        "system": "http://ihe.net/xds/connectathon/classCodes",
        "display": "History and Physical"
      }
    ]
  },
  "authenticator": {
    "reference": "Organization/f001"
  },
  "securityLabel": [
    {
      "coding": [
        {
          "code": "V",
          "system": "http://hl7.org/fhir/v3/Confidentiality",
          "display": "very restricted"
        }
      ]
    }
  ],
  "contained": [
    {
      "resourceType": "Practitioner",
      "id": "a2",
      "name": [
        {
          "given": [
            "Gerald"
          ],
          "family": "Smitty"
        }
      ]
    }
  ],
  "context": {
    "practiceSetting": {
      "coding": [
        {
          "code": "General Medicine",
          "system": "http://www.ihe.net/xds/connectathon/practiceSettingCodes",
          "display": "General Medicine"
        }
      ]
    },
    "sourcePatientInfo": {
      "reference": "Patient/xcda"
    },
    "period": {
      "start": "2004-12-23T08:00:00+11:00",
      "end": "2004-12-23T08:01:00+11:00"
    },
    "related": [
      {
        "identifier": {
          "system": "urn:ietf:rfc:3986",
          "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.2345"
        },
        "ref": {
          "reference": "Patient/xcda"
        }
      }
    ],
    "facilityType": {
      "coding": [
        {
          "code": "Outpatient",
          "system": "http://www.ihe.net/xds/connectathon/healthcareFacilityTypeCodes",
          "display": "Outpatient"
        }
      ]
    },
    "event": [
      {
        "coding": [
          {
            "code": "T-D8200",
            "system": "http://ihe.net/xds/connectathon/eventCodes",
            "display": "Arm"
          }
        ]
      }
    ],
    "encounter": {
      "reference": "Encounter/xcda"
    }
  },
  "custodian": {
    "reference": "Organization/f001"
  },
  "indexed": "2005-12-24T09:43:41+11:00",
  "docStatus": "preliminary",
  "identifier": [
    {
      "system": "urn:ietf:rfc:3986",
      "value": "urn:oid:1.3.6.1.4.1.21367.2005.3.7.1234"
    }
  ],
  "type": {
    "coding": [
      {
        "code": "34108-1",
        "system": "http://loinc.org",
        "display": "Outpatient Note"
      }
    ]
  },
  "id": "example",
  "subject": {
    "reference": "Patient/xcda"
  }
}

DocumentReference Structure


  
{
  "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 | appended | amended | entered-in-error
  "type" : { CodeableConcept }, // R!  Kind of document (LOINC if possible)
  "class" : { CodeableConcept }, // Categorization of document
  "subject" : { Reference(Patient|Practitioner|Group|Device) }, // Who/what is the subject of the document
  "created" : "<dateTime>", // Document creation time
  "indexed" : "<instant>", // R!  When this document reference was created
  "author" : [{ Reference(Practitioner|Organization|Device|Patient|
   RelatedPerson) }], // Who and/or what authored the document
  "authenticator" : { Reference(Practitioner|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 (title)
  "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) }, // 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" : [{ // Related identifiers or resources
      "identifier" : { Identifier }, // Identifier of related objects or events
      "ref" : { Reference(Any) } // Related Resource
    }]
  }
}


 

DocumentReference Search Parameters

The following search parameters can be used to query DocumentReference resources. Just submit the like so:

https://api.1up.health/fhir/stu3/DocumentReference?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
authenticatorreferenceauthenticator
authorreferenceauthor
classtextclass
createddatecreated
custodianreferencecustodian
descriptiontextdescription
encounterreferencecontext.encounter
eventtextcontext.event
facilitytextcontext.facilityType
formattextcontent.format
identifiertextmasterIdentifier, identifier
indexeddateindexed
languagetextcontent.attachment.language
locationuricontent.attachment.url
patientreferencesubject
perioddatecontext.period
related-idtextcontext.related.identifier
related-refreferencecontext.related.ref
relatestoreferencerelatesTo.target
relationtextrelatesTo.code
relationshipcompositerelatesTo
securitylabeltextsecurityLabel
settingtextcontext.practiceSetting
statustextstatus
subjectreferencesubject
typetexttype