DocumentReference

Property	Value
Publisher
Name	DocumentReference
URL	http://hl7.org/fhir/StructureDefinition/DocumentReference
Status	draft
Description
Abstract	false

Structure

Path	Cardinality	Type	Description
DocumentReference	0..*	DocumentReference	A 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.
DocumentReference.id	0..1	http://hl7.org/fhirpath/System.String	The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
DocumentReference.meta	0..1	Meta	The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
DocumentReference.implicitRules	0..1	uri	A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
DocumentReference.language	0..1	code	The base language in which the resource is written.
DocumentReference.text	0..1	Narrative	A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
DocumentReference.contained	0..*	Resource	These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
DocumentReference.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
DocumentReference.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
DocumentReference.masterIdentifier	0..1	Identifier	Document 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.
DocumentReference.identifier	0..*	Identifier	Other identifiers associated with the document, including version independent identifiers.
DocumentReference.status	1..1	code	The status of this document reference.
DocumentReference.docStatus	0..1	code	The status of the underlying document.
DocumentReference.type	0..1	CodeableConcept	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.
DocumentReference.category	0..*	CodeableConcept	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.
DocumentReference.subject	0..1	Reference	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).
DocumentReference.date	0..1	instant	When the document reference was created.
DocumentReference.author	0..*	Reference	Identifies who is responsible for adding the information to the document.
DocumentReference.authenticator	0..1	Reference	Which person or organization authenticates that this document is valid.
DocumentReference.custodian	0..1	Reference	Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.
DocumentReference.relatesTo	0..*	BackboneElement	Relationships that this document has with other document references that already exist.
DocumentReference.relatesTo.id	0..1	http://hl7.org/fhirpath/System.String	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
DocumentReference.relatesTo.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
DocumentReference.relatesTo.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
DocumentReference.relatesTo.code	1..1	code	The type of relationship that this document has with anther document.
DocumentReference.relatesTo.target	1..1	Reference	The target document of this relationship.
DocumentReference.description	0..1	string	Human-readable description of the source document.
DocumentReference.securityLabel	0..*	CodeableConcept	A 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.
DocumentReference.content	1..*	BackboneElement	The document and format referenced. There may be multiple content element repetitions, each with a different format.
DocumentReference.content.id	0..1	http://hl7.org/fhirpath/System.String	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
DocumentReference.content.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
DocumentReference.content.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
DocumentReference.content.attachment	1..1	Attachment	The document or URL of the document along with critical metadata to prove content has integrity.
DocumentReference.content.format	0..1	Coding	An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
DocumentReference.context	0..1	BackboneElement	The clinical context in which the document was prepared.
DocumentReference.context.id	0..1	http://hl7.org/fhirpath/System.String	Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
DocumentReference.context.extension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
DocumentReference.context.modifierExtension	0..*	Extension	May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
DocumentReference.context.encounter	0..*	Reference	Describes the clinical encounter or type of care that the document content is associated with.
DocumentReference.context.event	0..*	CodeableConcept	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.
DocumentReference.context.period	0..1	Period	The time period over which the service that is described by the document was provided.
DocumentReference.context.facilityType	0..1	CodeableConcept	The kind of facility where the patient was seen.
DocumentReference.context.practiceSetting	0..1	CodeableConcept	This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.
DocumentReference.context.sourcePatientInfo	0..1	Reference	The Patient Information as known when the document was published. May be a reference to a version specific, or contained.
DocumentReference.context.related	0..*	Reference	Related identifiers or resources associated with the DocumentReference.

Search Parameters

Name	Type	Description	Expression
_text	string	Search on the narrative of the resource
_content	string	Search on the entire content of the resource
_filter	token	Filter search parameter which supports a more sophisticated grammar for searching. See documentation for further details
_has	string	Provides limited support for reverse chaining - that is, selecting resources based on the properties of resources that refer to them (instead of chaining where resources can be selected based on the properties of resources that they refer to). See the FHIR search page for further documentation
_id	token	Logical id of this artifact	Resource.id
_lastUpdated	date	When the resource version last changed	Resource.meta.lastUpdated
_list	string	All resources in nominated list (by id, Type/id, url or one of the magic List types)
_profile	uri	Profiles this resource claims to conform to	Resource.meta.profile
_query	token	A custom search profile that describes a specific defined query operation
_security	token	Security Labels applied to this resource	Resource.meta.security
_source	uri	Identifies where the resource comes from	Resource.meta.source
_tag	token	Tags applied to this resource	Resource.meta.tag
_text	string	Search on the narrative text (html) of the resource
_type	token	Used when a search is performed in a context which doesn't limit the search to indicate which types are being searched. See the FHIR search page for further discussion
identifier	token	Multiple Resources: * AllergyIntolerance: External ids for this item* CarePlan: External Ids for this plan* CareTeam: External Ids for this team* Composition: Version-independent identifier for the Composition* Condition: A unique identifier of the condition record* Consent: Identifier for this record (external references)* DetectedIssue: Unique id for the detected issue* DeviceRequest: Business identifier for request/order* DiagnosticReport: An identifier for the report* DocumentManifest: Unique Identifier for the set of documents* DocumentReference: Master Version Specific Identifier* Encounter: Identifier(s) by which this encounter is known* EpisodeOfCare: Business Identifier(s) relevant for this EpisodeOfCare* FamilyMemberHistory: A search by a record identifier* Goal: External Ids for this goal* ImagingStudy: Identifiers for the Study, such as DICOM Study Instance UID and Accession number* Immunization: Business identifier* List: Business identifier* MedicationAdministration: Return administrations with this external identifier* MedicationDispense: Returns dispenses with this external identifier* MedicationRequest: Return prescriptions with this external identifier* MedicationStatement: Return statements with this external identifier* NutritionOrder: Return nutrition orders with this external identifier* Observation: The unique id for a particular observation* Procedure: A unique identifier for a procedure* RiskAssessment: Unique identifier for the assessment* ServiceRequest: Identifiers assigned to this order* SupplyDelivery: External identifier* SupplyRequest: Business Identifier for SupplyRequest* VisionPrescription: Return prescriptions with this external identifier	AllergyIntolerance.identifier / CarePlan.identifier / CareTeam.identifier / Composition.identifier / Condition.identifier / Consent.identifier / DetectedIssue.identifier / DeviceRequest.identifier / DiagnosticReport.identifier / DocumentManifest.masterIdentifier / DocumentManifest.identifier / DocumentReference.masterIdentifier / DocumentReference.identifier / Encounter.identifier / EpisodeOfCare.identifier / FamilyMemberHistory.identifier / Goal.identifier / ImagingStudy.identifier / Immunization.identifier / List.identifier / MedicationAdministration.identifier / MedicationDispense.identifier / MedicationRequest.identifier / MedicationStatement.identifier / NutritionOrder.identifier / Observation.identifier / Procedure.identifier / RiskAssessment.identifier / ServiceRequest.identifier / SupplyDelivery.identifier / SupplyRequest.identifier / VisionPrescription.identifier
patient	reference	Multiple Resources: * AllergyIntolerance: Who the sensitivity is for* CarePlan: Who the care plan is for* CareTeam: Who care team is for* ClinicalImpression: Patient or group assessed* Composition: Who and/or what the composition is about* Condition: Who has the condition?* Consent: Who the consent applies to* DetectedIssue: Associated patient* DeviceRequest: Individual the service is ordered for* DeviceUseStatement: Search by subject - a patient* DiagnosticReport: The subject of the report if a patient* DocumentManifest: The subject of the set of documents* DocumentReference: Who/what is the subject of the document* Encounter: The patient or group present at the encounter* EpisodeOfCare: The patient who is the focus of this episode of care* FamilyMemberHistory: The identity of a subject to list family member history items for* Flag: The identity of a subject to list flags for* Goal: Who this goal is intended for* ImagingStudy: Who the study is about* Immunization: The patient for the vaccination record* List: If all resources have the same subject* MedicationAdministration: The identity of a patient to list administrations for* MedicationDispense: The identity of a patient to list dispenses for* MedicationRequest: Returns prescriptions for a specific patient* MedicationStatement: Returns statements for a specific patient.* NutritionOrder: The identity of the person who requires the diet, formula or nutritional supplement* Observation: The subject that the observation is about (if patient)* Procedure: Search by subject - a patient* RiskAssessment: Who/what does assessment apply to?* ServiceRequest: Search by subject - a patient* SupplyDelivery: Patient for whom the item is supplied* VisionPrescription: The identity of a patient to list dispenses for	AllergyIntolerance.patient / CarePlan.subject.where(resolve() is Patient) / CareTeam.subject.where(resolve() is Patient) / ClinicalImpression.subject.where(resolve() is Patient) / Composition.subject.where(resolve() is Patient) / Condition.subject.where(resolve() is Patient) / Consent.patient / DetectedIssue.patient / DeviceRequest.subject.where(resolve() is Patient) / DeviceUseStatement.subject.where(resolve() is Patient) / DiagnosticReport.subject.where(resolve() is Patient) / DocumentManifest.subject.where(resolve() is Patient) / DocumentReference.subject.where(resolve() is Patient) / Encounter.subject.where(resolve() is Patient) / EpisodeOfCare.patient / FamilyMemberHistory.patient / Flag.subject.where(resolve() is Patient) / Goal.subject.where(resolve() is Patient) / ImagingStudy.subject.where(resolve() is Patient) / Immunization.patient / List.subject.where(resolve() is Patient) / MedicationAdministration.subject.where(resolve() is Patient) / MedicationDispense.subject.where(resolve() is Patient) / MedicationRequest.subject.where(resolve() is Patient) / MedicationStatement.subject.where(resolve() is Patient) / NutritionOrder.patient / Observation.subject.where(resolve() is Patient) / Procedure.subject.where(resolve() is Patient) / RiskAssessment.subject.where(resolve() is Patient) / ServiceRequest.subject.where(resolve() is Patient) / SupplyDelivery.patient / VisionPrescription.patient
type	token	Multiple Resources: * AllergyIntolerance: allergy / intolerance - Underlying mechanism (if known)* Composition: Kind of composition (LOINC if possible)* DocumentManifest: Kind of document set* DocumentReference: Kind of document (LOINC if possible)* Encounter: Specific type of encounter* EpisodeOfCare: Type/class - e.g. specialist referral, disease management	AllergyIntolerance.type / Composition.type / DocumentManifest.type / DocumentReference.type / Encounter.type / EpisodeOfCare.type
encounter	reference	Multiple Resources: * Composition: Context of the Composition* DeviceRequest: Encounter during which request was created* DiagnosticReport: The Encounter when the order was made* DocumentReference: Context of the document content* Flag: Alert relevant during encounter* List: Context in which list created* NutritionOrder: Return nutrition orders with this encounter identifier* Observation: Encounter related to the observation* Procedure: Encounter created as part of* RiskAssessment: Where was assessment performed?* ServiceRequest: An encounter in which this request is made* VisionPrescription: Return prescriptions with this encounter identifier	Composition.encounter / DeviceRequest.encounter / DiagnosticReport.encounter / DocumentReference.context.encounter.where(resolve() is Encounter) / Flag.encounter / List.encounter / NutritionOrder.encounter / Observation.encounter / Procedure.encounter / RiskAssessment.encounter / ServiceRequest.encounter / VisionPrescription.encounter
authenticator	reference	Who/what authenticated the document	DocumentReference.authenticator
author	reference	Who and/or what authored the document	DocumentReference.author
category	token	Categorization of document	DocumentReference.category
contenttype	token	Mime type of the content, with charset etc.	DocumentReference.content.attachment.contentType
custodian	reference	Organization which maintains the document	DocumentReference.custodian
date	date	When this document reference was created	DocumentReference.date
description	string	Human-readable description	DocumentReference.description
event	token	Main clinical acts documented	DocumentReference.context.event
facility	token	Kind of facility where patient was seen	DocumentReference.context.facilityType
format	token	Format/content rules for the document	DocumentReference.content.format
language	token	Human language of the content (BCP-47)	DocumentReference.content.attachment.language
location	uri	Uri where the data can be found	DocumentReference.content.attachment.url
period	date	Time of service that is being documented	DocumentReference.context.period
related	reference	Related identifiers or resources	DocumentReference.context.related
relatesto	reference	Target of the relationship	DocumentReference.relatesTo.target
relation	token	replaces / transforms / signs / appends	DocumentReference.relatesTo.code
security-label	token	Document security-tags	DocumentReference.securityLabel
setting	token	Additional details about where the content was created (e.g. clinical specialty)	DocumentReference.context.practiceSetting
status	token	current / superseded / entered-in-error	DocumentReference.status
subject	reference	Who/what is the subject of the document	DocumentReference.subject
relationship	composite	Combination of relation and relatesTo	DocumentReference.relatesTo