type: resource-definitionsresource: DocumentReference

DocumentReference Definitions

DocumentReference

A reference to a document

Definition: 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.

Comments: Usually, this is used for documents other than those defined by FHIR.

Cardinality: 0..*

Constraints: docRef-1 | warning | facilityType SHALL only be present if context is not an encounter | facilityType.empty() or context.where(resolve() is Encounter).empty(); docRef-2 | warning | practiceSetting SHALL only be present if context is not present | practiceSetting.empty() or context.where(resolve() is Encounter).empty()

Mappings: workflow=Event; fhircomposition=when describing a Composition; rim=Document[classCode="DOC" and moodCode="EVN"]; cda=when describing a CDA; w5=infrastructure.documents; xds=DocumentEntry

DocumentReference.identifier

Business identifiers for the document

Definition: Business identifiers assigned to this document reference by the performer and/or other systems. These identifiers remain constant as the resource is updated and propagates from server to server.

Comments: The structure and format of this identifier would be consistent with the specification corresponding to the format of the document. (e.g. for a DICOM standard document, a 64-character numeric UID; for an HL7 CDA format, the CDA Document Id root and extension).

Requirements: Document identifiers usually assigned by the source of the document, or other business identifiers such as XDS DocumentEntry.uniqueId and DocumentEntry.entryUUID. These identifiers are specific to this instance of the document.

Cardinality: 0..*

Type: Identifier

Summary: true

Mappings: workflow=Event.identifier; w5=FiveWs.identifier; fhircomposition=Composition.identifier; v2=TXA-12; rim=.id / .setId; xds=DocumentEntry.entryUUID, DocumentEntry.uniqueId; cda=ClinicalDocument/id

DocumentReference.version

An explicitly assigned identifier of a variation of the content in the DocumentReference

Comments: While each resource, including the DocumentReference itself, has its own version identifier, this is a formal identifier for the logical version of the DocumentReference as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

Cardinality: 0..1

Type: string

Summary: true

Mappings: fhircomposition=Composition.version; w5=FiveWs.version

DocumentReference.basedOn

Procedure that caused this media to be created

Definition: A procedure that is fulfilled in whole or in part by the creation of this media.

Requirements: Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

Aliases: fulfills

Cardinality: 0..*

Type: Reference(Appointment, AppointmentResponse, CarePlan, Claim, CommunicationRequest, Contract, CoverageEligibilityRequest, DeviceRequest, EnrollmentRequest, MedicationRequest, NutritionOrder, RequestOrchestration, ServiceRequest, VisionPrescription)

Mappings: workflow=Event.basedOn; rim=.outboundRelationship[typeCode=FLFS].target; xds=DocumentEntry.referenceIdList

DocumentReference.status

current | superseded | entered-in-error

Definition: The current state of the document reference.

Comments: 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.

Cardinality: 1..1

Type: code

Binding: required:document-reference-status

Summary: true

Is Modifier: true (Reason: This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid)

Mappings: workflow=Event.status; w5=FiveWs.status; v2=TXA-19; rim=interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"; xds=DocumentEntry.availabilityStatus

DocumentReference.docStatus

Definition: The status of the underlying document.

Comments: The document that is pointed to might be in various lifecycle states.

Cardinality: 0..1

Type: code

Binding: required:composition-status

Summary: true

Mappings: w5=FiveWs.status; fhircomposition=Composition.status; v2=TXA-17; rim=.statusCode

DocumentReference.modality

Imaging modality used

Definition: Imaging modality used. This may include both acquisition and non-acquisition modalities.

Cardinality: 0..*

Type: CodeableConcept

Binding: extensible:sect_CID_33.html

Summary: true

Mappings: w5=FiveWs.class

DocumentReference.type

Kind of document (LOINC if possible)

Definition: Specifies 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.

Comments: 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.

Cardinality: 0..1

Type: CodeableConcept

Binding: preferred:doc-typecodes

Summary: true

Mappings: workflow=Event.code; w5=FiveWs.what[x]; fhircomposition=Composition.type; v2=TXA-2; rim=./code; xds=DocumentEntry.typeCode; cda=ClinicalDocument/code/@code

The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.

DocumentReference.category

Categorization of document

Definition: A 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.

Comments: 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.

Aliases: class, classCode

Cardinality: 0..*

Type: CodeableConcept

Binding: example:referenced-item-category

Summary: true

Mappings: workflow=Event.category; w5=FiveWs.what[x]; fhircomposition=Composition.category; rim=.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code; xds=DocumentEntry.classCode; cda=Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code

DocumentReference.subject

Who/what is the subject of the document

Definition: Who 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).

Cardinality: 0..1

Type: Reference(Resource)

Summary: true

Mappings: workflow=Event.subject; w5=FiveWs.subject; fhircomposition=Composition.subject; v2=PID-3 (No standard way to define a Practitioner or Group subject in HL7 V2 MDM message); rim=.participation[typeCode="SBJ"].role[typeCode="PAT"]; xds=DocumentEntry.patientId; cda=ClinicalDocument/recordTarget/

DocumentReference.context

Encounter the document reference is part of

Definition: The Encounter during which this document reference was created or to which the creation of this record is tightly associated.

Comments: This will typically be the encounter the document reference was created during, but some document references may be initiated prior to or after the official completion of an encounter but still be tied to the context of the encounter (e.g. pre-admission lab tests).

Requirements: Links the document reference to the Encounter context. May also affect access control.

Conditions: docRef-1, docRef-2

Cardinality: 0..*

Type: Reference(Appointment, Encounter, EpisodeOfCare)

Summary: true

Mappings: workflow=Event.encounter; w5=FiveWs.context; fhircomposition=Composition.encounter; rim=unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])

DocumentReference.event

Main clinical acts documented

Definition: This 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.

Comments: 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.

Cardinality: 0..*

Type: CodeableReference

Binding: example:v3-ActCode

Mappings: fhircomposition=Composition.event.detail; rim=.code; xds=DocumentEntry.eventCodeList

DocumentReference.related

Related identifiers or resources associated with the document reference

Definition: Any other resource this document reference was created or to which the creation of this record is tightly associated.

Comments: Use only for references not covered by other elements.

Cardinality: 0..*

Type: Reference(Resource)

Mappings: fhircomposition=Composition.event.detail; rim=./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]; xds=DocumentEntry.referenceIdList

DocumentReference.bodyStructure

Body structure included

Definition: The anatomic structures included in the document.

Cardinality: 0..*

Type: CodeableReference

Binding: example:body-site

Summary: true

Mappings: rim=.targetSiteCode

DocumentReference.facilityType

Kind of facility where patient was seen

Definition: The kind of facility where the patient was seen.

Conditions: docRef-1

Cardinality: 0..1

Type: CodeableConcept

Binding: example:c80-facilitycodes

Mappings: fhircomposition=usually from a mapping to a local ValueSet; rim=.participation[typeCode="LOC"].role[classCode="DSDLOC"].code; xds=DocumentEntry.healthcareFacilityTypeCode; cda=usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code

DocumentReference.practiceSetting

Additional details about where the content was created (e.g. clinical specialty)

Definition: This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Comments: 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.

Requirements: This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Conditions: docRef-2

Cardinality: 0..1

Type: CodeableConcept

Binding: example:c80-practice-codes

Mappings: fhircomposition=usually from a mapping to a local ValueSet; rim=.participation[typeCode="LOC"].role[classCode="DSDLOC"].code; xds=DocumentEntry.practiceSettingCode; cda=usually from a mapping to a local ValueSet

DocumentReference.period

Time of service that is being documented

Definition: The time period over which the service that is described by the document was provided.

Cardinality: 0..1

Type: Period

Summary: true

Mappings: workflow=Event.occurrence[x]; w5=FiveWs.done[x]; fhircomposition=Composition.event.period; rim=.effectiveTime; xds=DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime; cda=ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value

DocumentReference.date

When this document reference was created

Definition: When the document reference was created.

Comments: Referencing/indexing time is used for tracking, organizing versions and searching. Provide the most precise timestamp available.

Aliases: indexed

Cardinality: 0..1

Type: dateTime

Summary: true

Mappings: workflow=Event.recorded; w5=FiveWs.recorded; fhircomposition=Composition.date; rim=.availabilityTime[type="TS"]

DocumentReference.author

Who and/or what authored the document

Definition: Identifies who is responsible for adding the information to the document.

Comments: Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant). Using Group is only allowed in the circumstance where the group represents a family or a household, and should not represent groups of Practitioners.

Cardinality: 0..*

Type: Reference(Practitioner, PractitionerRole, Organization, Device, Patient, RelatedPerson, CareTeam, Group)

Summary: true

Mappings: workflow=Event.performer.actor; w5=FiveWs.author; fhircomposition=Composition.author; v2=TXA-9 (No standard way to indicate a Device in HL7 V2 MDM message); rim=.participation[typeCode="AUT"].role[classCode="ASSIGNED"]; xds=DocumentEntry.author; cda=ClinicalDocument/author

DocumentReference.attester

Attests to accuracy of the document

Definition: A participant who has authenticated the accuracy of the document.

Comments: Only list each attester once.

Requirements: Identifies responsibility for the accuracy of the document content.

Cardinality: 0..*

Type: BackboneElement

Mappings: workflow=Event.performer; fhircomposition=Composition.attester; rim=.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]; xds=DocumentEntry.legalAuthenticator; cda=.authenticator/.legalAuthenticator

DocumentReference.attester.mode

personal | professional | legal | official

Definition: The type of attestation the authenticator offers.

Requirements: Indicates the level of authority of the attestation.

Cardinality: 1..1

Type: CodeableConcept

Binding: preferred:composition-attestation-mode

Mappings: workflow=Event.performer.function; fhircomposition=Composition.attester.mode; rim=unique(./modeCode); cda=implied by .authenticator/.legalAuthenticator

DocumentReference.attester.time

When the document was attested

Definition: When the document was attested by the party.

Requirements: Identifies when the information in the document was deemed accurate. (Things may have changed since then.).

Cardinality: 0..1

Type: dateTime

Mappings: fhircomposition=Composition.attester.time; rim=./time[type="TS" and isNormalDatatype()]; cda=.authenticator.time

DocumentReference.attester.party

Who attested the document

Definition: Who attested the document in the specified way.

Comments: Using Group is only allowed in the circumstance where the group represents a family or a household, and should not represent groups of Practitioners.

Requirements: Identifies who has taken on the responsibility for accuracy of the document content.

Cardinality: 0..1

Type: Reference(Patient, RelatedPerson, Practitioner, PractitionerRole, Organization, Group)

Mappings: workflow=Event.performer.actor; w5=FiveWs.witness; fhircomposition=Composition.attester.party; v2=TXA-10; rim=./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]; cda=.authenticator.assignedEnttty

DocumentReference.custodian

Organization which maintains the document

Definition: Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Comments: 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.

Cardinality: 0..1

Type: Reference(Organization)

Mappings: fhircomposition=Composition.custodian; rim=.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]

DocumentReference.relatesTo

Relationships to other documents

Definition: Relationships that this document has with other document references that already exist.

Comments: This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

Cardinality: 0..*

Type: BackboneElement

Summary: true

Mappings: fhircomposition=Composition.relatesTo; rim=.outboundRelationship; xds=DocumentEntry Associations

DocumentReference.relatesTo.code

The relationship type with another document

Definition: The type of relationship that this document has with anther document.

Comments: If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Cardinality: 1..1

Type: CodeableConcept

Binding: extensible:document-relationship-type

Summary: true

Mappings: fhircomposition=Composition.relatesTo.type; rim=.outboundRelationship.typeCode; xds=DocumentEntry Associations type; cda=ClinicalDocument/relatedDocument/typeCode

DocumentReference.relatesTo.target

Target of the relationship

Definition: The target document of this relationship.

Cardinality: 1..1

Type: Reference(DocumentReference)

Summary: true

Mappings: fhircomposition=Composition.relatesTo.targetReference; rim=.target[classCode="DOC", moodCode="EVN"].id; xds=DocumentEntry Associations reference; cda=ClinicalDocument/relatedDocument/parentDocument

DocumentReference.description

Human-readable description

Definition: Human-readable description of the source document.

Comments: What the document is about, a terse summary of the document.

Requirements: Helps humans to assess whether the document is of interest.

Cardinality: 0..1

Type: markdown

Summary: true

Mappings: v2=TXA-25; rim=.outboundRelationship[typeCode="SUBJ"].target.text; xds=DocumentEntry.comments

DocumentReference.securityLabel

Document security-tags

Definition: A set of Security-Tag codes specifying the level of privacy/security of the Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the data elements in DocumentReference, while DocumentReference.securityLabel contains the security labels for the document the reference refers to. The distinction recognizes that the document may contain sensitive information, while the DocumentReference is metadata about the document and thus might not be as sensitive as the document. For example: a psychotherapy episode may contain highly sensitive information, while the metadata may simply indicate that some episode happened.

Comments: 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.

Requirements: Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Cardinality: 0..*

Type: CodeableConcept

Binding: example:security-label-example

Summary: true

Mappings: fhircomposition=Bundle.meta.security; v2=TXA-18; rim=.confidentialityCode; xds=DocumentEntry.confidentialityCode; cda=ClinicalDocument/confidentialityCode/@code

DocumentReference.content

Document referenced

Definition: The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata.

Comments: content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

Requirements: Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

Cardinality: 1..*

Type: BackboneElement

Summary: true

Mappings: fhircomposition=Bundle(Composition+*); rim=document.text

DocumentReference.content.attachment

Where to access the document

Definition: The document or URL of the document along with critical metadata to prove content has integrity.

Cardinality: 1..1

Type: Attachment

Summary: true

Mappings: fhircomposition=Composition.language, Composition.title, Composition.date; v2=TXA-3 for mime type; rim=document.text; xds=DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.repositoryUniqueId, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime; cda=ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date

DocumentReference.content.profile

Content profile rules for the document

Definition: An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Comments: Note that IHE often issues URNs for formatCode codes, not all documents can be identified by a URI.

For FHIR content, .profile should indicate the structureDefinition profile canonical URI(s) that the content complies with.

Aliases: format, formatCode

Cardinality: 0..*

Type: BackboneElement

Summary: true

Mappings: fhircomposition=Composition.meta.profile; rim=document.text; xds=DocumentEntry.formatCode; cda=derived from the IHE Profile or Implementation Guide templateID

DocumentReference.content.profile.value[x]

Code|uri|canonical

Cardinality: 1..1

Type: Coding, uri, canonical

Binding: preferred:v3-HL7FormatCodes

Summary: true

Mappings: fhircomposition=Composition.meta.profile; rim=document.text; xds=DocumentEntry.formatCode; cda=derived from the IHE Profile or Implementation Guide templateID