Name Flags Card. Type Description & Constraints doco
. . DocumentReference Σ DomainResource A reference to a document
. . . masterIdentifier Σ 0..1 Identifier Master Version Specific Identifier
. . . identifier Σ 0..* Identifier Other identifiers for the document
. . . subject Σ 0..1 Reference( Patient | Practitioner | Group | Device) Who/what is the subject of the document
. . . type Σ 1..1 CodeableConcept Kind of document (LOINC if possible)
Document Type Value Set ( Preferred)
. . . class Σ 0..1 CodeableConcept Categorization of document
Document Class Value Set ( Example)
. . . author Σ 0..* Reference( Practitioner | Organization | Device | Patient | RelatedPerson) Who and/or what authored the document
. . . custodian Σ 0..1 Reference( Organization) Organization which maintains the document
. . . authenticator Σ 0..1 Reference( Practitioner | Organization) Who/what authenticated the document
. . . created Σ 0..1 dateTime Document creation time
. . . indexed Σ 1..1 instant When this document reference created
. . . status ?! Σ 1..1 code current | superseded | entered-in-error
DocumentReferenceStatus ( Required)
. . . docStatus Σ 0..1 CodeableConcept preliminary | final | appended | amended | entered-in-error
CompositionStatus ( Required)
. . . relatesTo ?! Σ 0..* BackboneElement Relationships to other documents
. . . . code Σ 1..1 code replaces | transforms | signs | appends
DocumentRelationshipType ( Required)
. . . . target Σ 1..1 Reference( DocumentReference) Target of the relationship
. . . description Σ 0..1 string Human-readable description (title)
. . . securityLabel Σ 0..* CodeableConcept Document security-tags
All Security Labels ( Extensible)
. . . content Σ 1..* BackboneElement Document referenced
. . . . attachment Σ 1..1 Attachment Where to access the document
. . . . format Σ 0..* Coding Format/content rules for the document
DocumentReference Format Code Set ( Preferred)
. . . context Σ 0..1 BackboneElement Clinical context of document
. . . . encounter Σ 0..1 Reference( Encounter) Context of the document content
. . . . event Σ 0..* CodeableConcept Main Clinical Acts Documented
v3 Code System ActCode ( Example)
. . . . period Σ 0..1 Period Time of service that is being documented
. . . . facilityType Σ 0..1 CodeableConcept Kind of facility where patient was seen
Facility Type Code Value Set ( Example)
. . . . practiceSetting Σ 0..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Practice Setting Code Value Set ( Example)
. . . . sourcePatientInfo Σ 0..1 Reference( Patient) Patient demographics from source
. . . . related Σ 0..* BackboneElement Related identifiers or resources
. . . . . identifier Σ 0..1 Identifier Identifier of related objects or events
. . . . . ref Σ 0..1 Reference( Any) Related Resource

doco Documentation for this format