DocumentReference - FHIR Resource (r4)


This DocumentReference Resource uses the FHIR API standard for access and structure.

Validate an DocumentReference FHIR Resource (r4)



Resource Attributes

AttributeField is listTypeDescription
authenticatorfalseReference# Who/what authenticated the document
authortrueReference# "author" : [{ Reference(Practitioner|PractitionerRole|Organization|Device|
categorytrueCodeableConcept# Categorization of document
contenttrueData Type# Document referenced
contextfalseData Type# Clinical context of document
custodianfalseReference# Organization which maintains the document
datefalseinstant# When this document reference was created
descriptionfalsestring# Human-readable description
docStatusfalsecode# preliminary | final | amended | entered-in-error
identifiertrueIdentifier# Other identifiers for the document
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statusfalsecode# current | superseded | entered-in-error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

{
  "resourceType": "Bundle",
  "id": "xds",
  "meta": {
    "lastUpdated": "2013-07-01T13:11:33Z"
  },
  "type": "transaction",
  "entry": [
    {
      "fullUrl": "urn:uuid:3fdc72f4-a11d-4a9d-9260-a9f745779e1d",
      "resource": {
        "resourceType": "DocumentReference",
        "meta": {
          "lastUpdated": "2013-07-01T13:11:33Z"
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">\n\n\t\t\t\t\t\t<a href=\"http://localhost:9556/svc/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32\">Document: urn:oid:129.6.58.92.88336</a>undefined, created 24/12/2005\n\t\t\t\t\t</div>"
        },
        "masterIdentifier": {
          "system": "urn:ietf:rfc:3986",
          "value": "urn:oid:129.6.58.92.88336"
        },
        "status": "current",
        "type": {
          "coding": [
            {
              "system": "http://ihe.net/connectathon/classCodes",
              "code": "History and Physical",
              "display": "History and Physical"
            }
          ]
        },
        "category": [
          {
            "coding": [
              {
                "system": "http://loinc.org",
                "code": "47039-3",
                "display": "Inpatient Admission history and physical note"
              }
            ]
          }
        ],
        "subject": {
          "reference": "Patient/a2"
        },
        "date": "2013-07-01T23:11:33+10:00",
        "author": [
          {
            "reference": "Practitioner/a3"
          },
          {
            "reference": "Practitioner/a4"
          }
        ],
        "description": "Physical",
        "securityLabel": [
          {
            "coding": [
              {
                "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality",
                "code": "N",
                "display": "normal"
              }
            ]
          }
        ],
        "content": [
          {
            "attachment": {
              "contentType": "text/plain",
              "language": "en-US",
              "url": "http://localhost:9556/svc/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32",
              "title": "Physical",
              "creation": "2005-12-24"
            },
            "format": {
              "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
              "code": "urn:ihe:pcc:handp:2008"
            }
          }
        ],
        "context": {
          "period": {
            "start": "2004-12-23T08:00:00+10:00",
            "end": "2004-12-23T08:01:00+10:00"
          },
          "practiceSetting": {
            "coding": [
              {
                "system": "http://ihe.net/connectathon/practiceSettingCodes",
                "code": "General Medicine",
                "display": "General Medicine"
              }
            ]
          }
        }
      },
      "request": {
        "method": "POST",
        "url": "DocumentReference"
      }
    },
    {
      "fullUrl": "http://localhost:9556/svc/fhir/Patient/a2",
      "resource": {
        "resourceType": "Patient",
        "id": "a2",
        "meta": {
          "lastUpdated": "2013-07-01T13:11:33Z"
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Person DOE, John, M, dob: 27/05/1956</div>"
        },
        "identifier": [
          {
            "use": "usual",
            "value": "MRN"
          }
        ],
        "name": [
          {
            "use": "usual",
            "text": "DOE, John",
            "family": "Doe",
            "given": [
              "John"
            ]
          }
        ],
        "birthDate": "1956-05-27"
      },
      "request": {
        "method": "POST",
        "url": "Patient",
        "ifNoneExist": "Patient?identifier=http://acme.org/xds/patients!89765a87b"
      }
    },
    {
      "fullUrl": "http://localhost:9556/svc/fhir/Practitioner/a3",
      "resource": {
        "resourceType": "Practitioner",
        "id": "a3",
        "meta": {
          "lastUpdated": "2013-07-01T13:11:33Z"
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Author Gerald Smitty @ Cleveland Clinic</div>"
        },
        "name": [
          {
            "use": "usual",
            "family": "Smitty",
            "given": [
              "Gerald"
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Practitioner"
      }
    },
    {
      "fullUrl": "http://localhost:9556/svc/fhir/Practitioner/a4",
      "resource": {
        "resourceType": "Practitioner",
        "id": "a4",
        "meta": {
          "lastUpdated": "2013-07-01T13:11:33Z"
        },
        "text": {
          "status": "generated",
          "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">Author Person @ Cleveland Clinic</div>"
        },
        "name": [
          {
            "use": "usual",
            "family": "Dopplemeyer",
            "given": [
              "Sherry"
            ]
          }
        ]
      },
      "request": {
        "method": "POST",
        "url": "Practitioner"
      }
    },
    {
      "fullUrl": "http://localhost:9556/svc/fhir/Binary/1e404af3-077f-4bee-b7a6-a9be97e1ce32",
      "resource": {
        "resourceType": "Binary",
        "id": "1e404af3-077f-4bee-b7a6-a9be97e1ce32",
        "meta": {
          "lastUpdated": "2013-07-01T13:11:33Z"
        },
        "contentType": "text/plain",
        "data": "YXNkYXNkYXNkYXNkYXNk"
      },
      "request": {
        "method": "POST",
        "url": "Binary"
      }
    }
  ]
}

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 | 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
  }
}

DocumentReference Search Parameters

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

https://api.1up.health/fhir/r4/DocumentReference?query-param=queryvalue
Search ParameterField TypeResource Fields Searched
authenticatorreferenceauthenticator
authorreferenceauthor
categorytextcategory
contenttypetextcontent.attachment.contentType
custodianreferencecustodian
datedatedate
descriptiontextdescription
encounterreferencecontext.encounter
eventtextcontext.event
facilitytextcontext.facilityType
formattextcontent.format
identifiertextmasterIdentifier
languagetextcontent.attachment.language
locationuricontent.attachment.url
patientreferencesubject.where
perioddatecontext.period
relatedreferencecontext.related
relatestoreferencerelatesTo.target
relationtextrelatesTo.code
relationshipcompositerelatesTo
security-labeltextsecurityLabel
settingtextcontext.practiceSetting
statustextstatus
subjectreferencesubject
typetexttype