Structure Definition: DocumentReference
Canonical URL: https://signalbhn.org/fhir/StructureDefinition/documentreference
Simplifier project page: Signal DocumentReference Profile
Derived from: DocumentReference (R4)
Module: File Exchange and Communications Module
Formal profile content
DocumentReference | I | DocumentReference | There are no (further) constraints on this element Element IdDocumentReference A reference to a document DefinitionA reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text. Usually, this is used for documents other than those defined by FHIR.
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masterIdentifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdDocumentReference.masterIdentifier Master Version Specific Identifier DefinitionDocument identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document. The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.). CDA Document Id extension and root.
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdDocumentReference.identifier Other identifiers for the document DefinitionOther identifiers associated with the document, including version independent identifiers.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.status current | superseded | entered-in-error DefinitionThe status of this document reference. This is the status of the DocumentReference object, which might be independent from the docStatus element. This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid. The status of the document reference. DocumentReferenceStatus (required)Constraints
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docStatus | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.docStatus preliminary | final | amended | entered-in-error DefinitionThe status of the underlying document. The document that is pointed to might be in various lifecycle states. Status of the underlying document. CompositionStatus (required)Constraints
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdDocumentReference.type Kind of document (LOINC if possible) DefinitionSpecifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced. Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents. Precise type of clinical document. DocumentTypeValueSet (preferred)Constraints
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category | Σ | 0..* | CodeableConceptBinding | Element IdDocumentReference.category Categorization of document Alternate namesclaxs DefinitionA categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type. Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching. High-level kind of a clinical document at a macro level. SignalFileRepoClassification (required)Constraints
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subject | Σ I | 0..1 | Reference(Patient | Practitioner | Group | Device) | There are no (further) constraints on this element Element IdDocumentReference.subject Who/what is the subject of the document DefinitionWho or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Practitioner | Group | Device) Constraints
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date | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdDocumentReference.date When this document reference was created Alternate namesindexed DefinitionWhen the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching.
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author | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdDocumentReference.author Who and/or what authored the document DefinitionIdentifies who is responsible for adding the information to the document. Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Constraints
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authenticator | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element IdDocumentReference.authenticator Who/what authenticated the document DefinitionWhich person or organization authenticates that this document is valid. Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator. Reference(Practitioner | PractitionerRole | Organization) Constraints
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custodian | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdDocumentReference.custodian Organization which maintains the document DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the document. Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.
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relatesTo | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.relatesTo Relationships to other documents DefinitionRelationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
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code | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this document has with anther document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required)Constraints
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target | Σ I | 1..1 | Reference(DocumentReference) | There are no (further) constraints on this element Element IdDocumentReference.relatesTo.target Target of the relationship DefinitionThe target document of this relationship. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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description | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDocumentReference.description Human-readable description DefinitionHuman-readable description of the source document. Helps humans to assess whether the document is of interest. What the document is about, a terse summary of the document.
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securityLabel | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdDocumentReference.securityLabel Document security-tags DefinitionA set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to. Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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content | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.content Document referenced DefinitionThe document and format referenced. There may be multiple content element repetitions, each with a different format.
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attachment | Σ I | 1..1 | Attachment | There are no (further) constraints on this element Element IdDocumentReference.content.attachment Where to access the document DefinitionThe document or URL of the document along with critical metadata to prove content has integrity. When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".
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format | Σ | 0..1 | CodingBinding | There are no (further) constraints on this element Element IdDocumentReference.content.format Format/content rules for the document DefinitionAn identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. Document Format Codes. DocumentReferenceFormatCodeSet (preferred)Constraints
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context | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.context Clinical context of document DefinitionThe clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents.
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encounter | I | 0..* | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element IdDocumentReference.context.encounter Context of the document content DefinitionDescribes the clinical encounter or type of care that the document content is associated with. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Encounter | EpisodeOfCare) Constraints
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event | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.event Main clinical acts documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation. This list of codes represents the main clinical acts being documented. v3.ActCode (example)Constraints
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdDocumentReference.context.period Time of service that is being documented DefinitionThe time period over which the service that is described by the document was provided. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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facilityType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.facilityType Kind of facility where patient was seen DefinitionThe kind of facility where the patient was seen. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. XDS Facility Type. FacilityTypeCodeValueSet (example)Constraints
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practiceSetting | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.practiceSetting Additional details about where the content was created (e.g. clinical specialty) DefinitionThis property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. Additional details about where the content was created (e.g. clinical specialty). PracticeSettingCodeValueSet (example)Constraints
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sourcePatientInfo | I | 0..1 | Reference(Patient) | There are no (further) constraints on this element Element IdDocumentReference.context.sourcePatientInfo Patient demographics from source DefinitionThe Patient Information as known when the document was published. May be a reference to a version specific, or contained. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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related | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdDocumentReference.context.related Related identifiers or resources DefinitionRelated identifiers or resources associated with the DocumentReference. May be identifiers or resources that caused the DocumentReference or referenced Document to be created.
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DocumentReference | I | DocumentReference | There are no (further) constraints on this element Element IdDocumentReference A reference to a document DefinitionA reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text. Usually, this is used for documents other than those defined by FHIR.
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masterIdentifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element IdDocumentReference.masterIdentifier Master Version Specific Identifier DefinitionDocument identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document. The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.). CDA Document Id extension and root.
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identifier | Σ | 0..* | Identifier | There are no (further) constraints on this element Element IdDocumentReference.identifier Other identifiers for the document DefinitionOther identifiers associated with the document, including version independent identifiers.
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status | Σ ?! | 1..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.status current | superseded | entered-in-error DefinitionThe status of this document reference. This is the status of the DocumentReference object, which might be independent from the docStatus element. This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid. The status of the document reference. DocumentReferenceStatus (required)Constraints
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docStatus | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.docStatus preliminary | final | amended | entered-in-error DefinitionThe status of the underlying document. The document that is pointed to might be in various lifecycle states. Status of the underlying document. CompositionStatus (required)Constraints
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element IdDocumentReference.type Kind of document (LOINC if possible) DefinitionSpecifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced. Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents. Precise type of clinical document. DocumentTypeValueSet (preferred)Constraints
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category | Σ | 0..* | CodeableConceptBinding | Element IdDocumentReference.category Categorization of document Alternate namesclaxs DefinitionA categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type. Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching. High-level kind of a clinical document at a macro level. SignalFileRepoClassification (required)Constraints
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subject | Σ I | 0..1 | Reference(Patient | Practitioner | Group | Device) | There are no (further) constraints on this element Element IdDocumentReference.subject Who/what is the subject of the document DefinitionWho or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure). References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | Practitioner | Group | Device) Constraints
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date | Σ | 0..1 | instant | There are no (further) constraints on this element Element IdDocumentReference.date When this document reference was created Alternate namesindexed DefinitionWhen the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching.
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author | Σ I | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | There are no (further) constraints on this element Element IdDocumentReference.author Who and/or what authored the document DefinitionIdentifies who is responsible for adding the information to the document. Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Constraints
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authenticator | I | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element IdDocumentReference.authenticator Who/what authenticated the document DefinitionWhich person or organization authenticates that this document is valid. Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator. Reference(Practitioner | PractitionerRole | Organization) Constraints
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custodian | I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element IdDocumentReference.custodian Organization which maintains the document DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the document. Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.
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relatesTo | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.relatesTo Relationships to other documents DefinitionRelationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
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code | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element IdDocumentReference.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this document has with anther document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents. DocumentRelationshipType (required)Constraints
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target | Σ I | 1..1 | Reference(DocumentReference) | There are no (further) constraints on this element Element IdDocumentReference.relatesTo.target Target of the relationship DefinitionThe target document of this relationship. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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description | Σ | 0..1 | string | There are no (further) constraints on this element Element IdDocumentReference.description Human-readable description DefinitionHuman-readable description of the source document. Helps humans to assess whether the document is of interest. What the document is about, a terse summary of the document.
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securityLabel | Σ | 0..* | CodeableConceptBinding | There are no (further) constraints on this element Element IdDocumentReference.securityLabel Document security-tags DefinitionA set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to. Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended. The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects. Security Labels from the Healthcare Privacy and Security Classification System. All Security Labels (extensible)Constraints
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content | Σ | 1..* | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.content Document referenced DefinitionThe document and format referenced. There may be multiple content element repetitions, each with a different format.
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attachment | Σ I | 1..1 | Attachment | There are no (further) constraints on this element Element IdDocumentReference.content.attachment Where to access the document DefinitionThe document or URL of the document along with critical metadata to prove content has integrity. When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent".
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format | Σ | 0..1 | CodingBinding | There are no (further) constraints on this element Element IdDocumentReference.content.format Format/content rules for the document DefinitionAn identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType. Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. Document Format Codes. DocumentReferenceFormatCodeSet (preferred)Constraints
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context | Σ | 0..1 | BackboneElement | There are no (further) constraints on this element Element IdDocumentReference.context Clinical context of document DefinitionThe clinical context in which the document was prepared. These values are primarily added to help with searching for interesting/relevant documents.
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encounter | I | 0..* | Reference(Encounter | EpisodeOfCare) | There are no (further) constraints on this element Element IdDocumentReference.context.encounter Context of the document content DefinitionDescribes the clinical encounter or type of care that the document content is associated with. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Encounter | EpisodeOfCare) Constraints
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event | 0..* | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.event Main clinical acts documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation. This list of codes represents the main clinical acts being documented. v3.ActCode (example)Constraints
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element IdDocumentReference.context.period Time of service that is being documented DefinitionThe time period over which the service that is described by the document was provided. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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facilityType | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.facilityType Kind of facility where patient was seen DefinitionThe kind of facility where the patient was seen. Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination. XDS Facility Type. FacilityTypeCodeValueSet (example)Constraints
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practiceSetting | 0..1 | CodeableConcept | There are no (further) constraints on this element Element IdDocumentReference.context.practiceSetting Additional details about where the content was created (e.g. clinical specialty) DefinitionThis property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty. This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content. This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC. Additional details about where the content was created (e.g. clinical specialty). PracticeSettingCodeValueSet (example)Constraints
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sourcePatientInfo | I | 0..1 | Reference(Patient) | There are no (further) constraints on this element Element IdDocumentReference.context.sourcePatientInfo Patient demographics from source DefinitionThe Patient Information as known when the document was published. May be a reference to a version specific, or contained. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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related | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element IdDocumentReference.context.related Related identifiers or resources DefinitionRelated identifiers or resources associated with the DocumentReference. May be identifiers or resources that caused the DocumentReference or referenced Document to be created.
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{ "resourceType": "StructureDefinition", "id": "signal-documentreference", "url": "https://signalbhn.org/fhir/StructureDefinition/documentreference", "name": "SignalDocumentReference", "title": "DocumentReference Profile", "status": "draft", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "DocumentReference", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DocumentReference", "derivation": "constraint", "differential": { "element": [ { "id": "DocumentReference.category", "path": "DocumentReference.category", "binding": { "strength": "required", "valueSet": "https://signalbhn.org/fhir/us/core/ValueSet/signal-filerepo-classification" } } ] } }
Profile usage
The DocumentReference resource will be used to store metadata about files uploaded and interchanged between a service organization and a provider agency or location so they can be discovered and managed. The files may be of any kind and used for any purpose. In the case they relate to a specific encounter or episode of care (admission), those references SHOULD be provided.
Note: Although there exists a US Core DocumentReference, it is geared towards Clinical Notes and requires a Patient reference. Signal's DocumentReference will be used in a much more general capacity and will not always have an explicit Patient.
File Storage
Files are intended to be stored in an external storage (e.g. Azure storage) and be linked with a resolvable URI for parties with proper permissions.
In all instances, the correct mimetype SHALL be specified for the attached file.
Additional notes
Additional notes and corespondance between a service organization and provider about the document MAY be stored as additional attachments
ALTERNATIVELY, additional notes on a DocumentReference file may be added as a new DocumentReference that uses the relatesTo.code = appends
and references it in relatesto.target
.
Profile element notes
.status
- will contain
current
unless it has been marked asentered-in-error
orsuperseded
- Alternatively the file may be deleted from the system
.description
- MAY be used for document name or short description that is searchable
.type
- Kind of document, specified by LOINC, which defines the FHIR document code
- Especially important to lend context to clinical notes
.category
- Categorization of document, "classification" in Signal's glossary
- Will be used for business purposes to group and label documents
- FUTURE - SHOULD contain LOINC codes to matching concepts
.content.attachment.url
- SHALL use the
.attachment.url
field to reference files; do not directly attach data to avoid very large file returns from FHIR
.content.attachment.contentType
- SHALL be populated with the appropriate MimeType, either identified programmatically or during entry
- MAY be used to render document for display
.content.attachment.title
- MAY be listed for display purposes
- Currently NOT used in search parameters; use the
.description
field for searchable information
.content.format - FUTURE - potential future add
- SHOULD be fixed value at
urn:ihe:iti:xds:2017:mimeTypeSufficient
- Requires proper
DocumentReference.content.attachment.contentType
code associated withDocumentReference.content.attachment.url
.subject
- Reference the Patient in cases where document specifically discusses an individual that is subject of services
- Note: In DocumentReference (R5) this field references ANY file, but will likely still be Patient in Signal's context
.author
- MAY represent the Organization that creates the document, since Users are not stored in FHIR
.custodian
- SHOULD represent the provider Organization that has created and maintaining the document
.context.encounter
- SHOULD reference the encounter and/or episode of care for which the services were performed related to the document
.context.sourcePatientInfo
- Reference the Patient in cases where document specifically discusses an individual that is subject of services
.context.related
- References any other resources or identifiers that may be referenced or related to the file