Pan-Canadian eReferral-eConsult (CA:eReC)
DFT - The specification is currently in development and subject to change. For a full list of available versions, see the Directory of published versions
http://hl7.org/fhir/StructureDefinition/DocumentReference
A reference to a document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.
DocumentReference | C | DocumentReference | |
id | Σ | 0..1 | string |
meta | S Σ | 0..1 | Meta |
id | 0..1 | string | |
extension | C | 0..* | Extension |
versionId | Σ | 0..1 | id |
lastUpdated | Σ | 0..1 | instant |
source | Σ | 0..1 | uri |
profile | S Σ | 0..* | canonical(StructureDefinition) |
security | Σ | 0..* | CodingBinding |
tag | Σ | 0..* | Coding |
implicitRules | Σ ?! | 0..1 | uri |
language | 0..1 | codeBinding | |
text | 0..1 | Narrative | |
contained | 0..* | Resource | |
extension | C | 0..* | Extension |
modifierExtension | ?! C | 0..* | Extension |
masterIdentifier | Σ | 0..1 | Identifier |
identifier | S Σ | 0..* | Identifier |
id | 0..1 | string | |
extension | C | 0..* | Extension |
use | Σ ?! | 0..1 | codeBinding |
type | Σ | 0..1 | CodeableConceptBinding |
system | S Σ | 1..1 | uri |
value | S Σ | 1..1 | string |
period | Σ | 0..1 | Period |
assigner | Σ | 0..1 | Reference(Organization) |
status | S Σ ?! | 1..1 | codeBindingPattern |
docStatus | Σ | 0..1 | codeBinding |
type | S Σ | 0..1 | CodeableConceptBinding |
category | Σ | 0..* | CodeableConcept |
subject | S Σ | 0..1 | Reference(Patient) |
id | 0..1 | string | |
extension | C | 0..* | Extension |
reference | S Σ C | 0..1 | string |
type | Σ | 0..1 | uriBinding |
identifier | S Σ | 0..1 | Identifier |
id | 0..1 | string | |
extension | C | 0..* | Extension |
use | Σ ?! | 0..1 | codeBinding |
type | Σ | 0..1 | CodeableConceptBinding |
system | S Σ | 1..1 | uri |
value | S Σ | 1..1 | string |
period | Σ | 0..1 | Period |
assigner | Σ | 0..1 | Reference(Organization) |
display | Σ | 0..1 | string |
date | S Σ | 0..1 | instant |
author | S Σ | 0..* | Reference(Practitioner | PractitionerRole) |
id | 0..1 | string | |
extension | C | 0..* | Extension |
reference | S Σ C | 0..1 | string |
type | Σ | 0..1 | uriBinding |
identifier | S Σ | 0..1 | Identifier |
id | 0..1 | string | |
extension | C | 0..* | Extension |
use | Σ ?! | 0..1 | codeBinding |
type | Σ | 0..1 | CodeableConceptBinding |
system | S Σ | 1..1 | uri |
value | S Σ | 1..1 | string |
period | Σ | 0..1 | Period |
assigner | Σ | 0..1 | Reference(Organization) |
display | Σ | 0..1 | string |
authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | |
custodian | 0..1 | Reference(Organization) | |
relatesTo | Σ | 0..* | BackboneElement |
id | 0..1 | string | |
extension | C | 0..* | Extension |
modifierExtension | Σ ?! C | 0..* | Extension |
code | Σ | 1..1 | codeBinding |
target | Σ | 1..1 | Reference(DocumentReference) |
description | Σ | 0..1 | string |
securityLabel | Σ | 0..* | CodeableConceptBinding |
content | S Σ | 1..1 | BackboneElement |
id | 0..1 | string | |
extension | C | 0..* | Extension |
modifierExtension | Σ ?! C | 0..* | Extension |
attachment | S Σ | 1..1 | Attachment |
format | Σ | 0..1 | CodingBinding |
context | S Σ | 1..1 | BackboneElement |
id | 0..1 | string | |
extension | C | 0..* | Extension |
modifierExtension | Σ ?! C | 0..* | Extension |
encounter | 0..* | Reference(Encounter | EpisodeOfCare) | |
event | 0..* | CodeableConcept | |
period | Σ | 0..1 | Period |
facilityType | 0..1 | CodeableConcept | |
practiceSetting | 0..1 | CodeableConcept | |
sourcePatientInfo | 0..1 | Reference(Patient) | |
related | S | 1..1 | Reference(ServiceRequest) |
id | 0..1 | string | |
extension | C | 0..* | Extension |
reference | S Σ C | 0..1 | string |
type | Σ | 0..1 | uriBinding |
identifier | S Σ | 0..1 | Identifier |
id | 0..1 | string | |
extension | C | 0..* | Extension |
use | S Σ ?! | 1..1 | codeBinding |
type | Σ | 0..1 | CodeableConceptBinding |
system | S Σ | 1..1 | uri |
value | S Σ | 1..1 | string |
period | Σ | 0..1 | Period |
assigner | Σ | 0..1 | Reference(Organization) |
display | Σ | 0..1 | string |
DocumentReference | DocumentReference | ||
meta | S | ||
profile | S | ||
identifier | S | ||
system | S | 1.. | |
value | S | 1.. | |
status | S | Pattern | |
type | S | ||
subject | S | Reference(Patient) | |
reference | S | ||
identifier | S | ||
system | S | 1.. | |
value | S | 1.. | |
date | S | ||
author | S | Reference(Practitioner | PractitionerRole) | |
reference | S | ||
identifier | S | ||
system | S | 1.. | |
value | S | 1.. | |
content | S | 1..1 | |
attachment | S | ||
context | S | 1..1 | |
related | S | 1..1 | Reference(ServiceRequest) |
reference | S | ||
identifier | S | ||
use | S | 1.. | |
system | S | 1.. | |
value | S | 1.. |
The primary use of the DocumentReference in this IG is to exchange binary .content
(attachments to ServiceRequests) in DirectMessaging integrations.
In the referral workflow multiple, large binary files could potentially be referenced as ServiceRequest.supportingInfo
. To reduce message size, message performance and scalability, implementers are strongly recommended to use .content.attachment.url
to enable asyncronous retrieval of binary attachments from a secure server instead of passing attachments within a message as base64 .content.attachment.data
. For further background and discussion about potential approaches see: https://infocentral.infoway-inforoute.ca/en/resources/docs/3551-documentreference/view-document
.id
Bundle.entry.fullUrl
).identifier
identifier.system
and identifier.value
SHALL be mustSupport whenever there is a reference or identifier present.status
.type
.subject
.subject
is populated, it SHALL reference the same Patient resource as ServiceRequest.subject
.reference
a resource included in the message as a Bundle.entry
.date
.content.attachment
.content.attachment.url
to enable the recipient to securely retrieve a binary attachment after the message is received instead of passing large documents as base64 .content.attachment.data
.context.related
.reference
to a resource included in the message as a Bundle.entry
, or.identifier
populated with the use
, system
and value
elements populated with the official ServiceRequest.identifier
received from the Source System