Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
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 Σ | 1..1 | code | current | superseded | entered-in-error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 |
Documentation for this format |