topic: StructureDefinition-DocumentReference

Profiles & Operations > Structure Definition: DocumentReference Profile

Profile: DocumentReference

Canonical URL:http://ontariohealth.ca/fhir/ehr/StructureDefinition/profile-documentReference

Simplifier project page:

Derived from: DocumentReference (R4)

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work

Usage

The DocumentReference resource supports the submission and retrieval of a clinical document.

Notes

.identifier

• SHALL contain an identifier of the document. This could represent different identifiers for different domains. For acCDR, this is the document identifier (i.e. filler order number).

.status

• SHALL contain the status of the DcoumentReference such as "currrent", "entered-in-error", "superseded".

.docStatus

• SHALL contain the status of the document (preliminary, final, amended, etc)

.type

• SHALL contain a local documen type from the source system
• SHOULD also contain a Connecting Ontario LOINC code mapped to the local document type code

.category

• SHOULD contain document ontology part codes from LOINC plus any CGTA ontology codes locally defined by Ontario Health

.subject

• SHALL contain a reference to the patient

.date

• SHALL contain the date when the document is created

.author

• SHOULD contain a reference to the author, which could be Practitioner, PractitionerRole, or Organization resource

.custodian

• SHALL contains a reference to the organization as the UAO of the document

.authenticator

• MAY contain a reference to authenticator of the document,which could be Practitioner, PractitionerRole, or Organization resource

.relatesTo

• MAY contain reference to other DocumentReference instances that point to the same document, if they exist

.description

• SHOULD contain the textual description of the document. For acCDR, this contains the local description defined by the sending HIC in OBR-4.2.

.content.attachment.url

• SHALL contain the 'url' field for the document. User can issue another HTTP GET to the link to retrieve the document.

.context.encounter

• SHOULD contain reference to the encounter relevant to the document

.context.event

• SHOULD contain a code that indicates the clinical event. For acCDR, this indicates the patient visit class defined in PV1-2 (e.g. inpatient visit, outpatient visit, etc)

.context.facilityType

• SHOULD contain a code indicating the facility type of the event. For acCDR, this is the type of the sending organization

.context.practiceSetting

• SHOULD contain the clinical service related to the visit. For acCDR, this maps to PV1-10 (hospital service type)