description: Base StructureDefinition for DocumentReference Resource package_name: hl7.fhir.r2b.examples derivation: specialization name: DocumentReference type: null elements: indexed: isModifier: false short: When this document reference created index: 9 comments: Referencing/indexing time is used for tracking, organizing versions and searching. type: instant mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.indexed} isSummary: true description: isModifier: false short: Human-readable description (title) index: 15 comments: What the document is about, rather than a terse summary of the document. It is commonly the case that records do not have a title and are collectively referred to by the display name of Record code (e.g. a "consultation" or "progress note"). type: string mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.description} isSummary: true docStatus: isModifier: false short: preliminary | final | appended | amended | entered-in-error index: 11 comments: The document that is pointed to might be in various lifecycle states. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.docStatus} isSummary: true content: min: 1 isModifier: false short: Document referenced index: 17 type: BackboneElement mustSupport: false array: true elements: attachment: isModifier: false short: Where to access the document index: 18 type: Attachment mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.content.attachment} isSummary: true format: isModifier: false short: Format/content rules for the document index: 19 comments: Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI. type: Coding mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.content.format} isSummary: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.content} required: [attachment] isSummary: true type: isModifier: false short: Kind of document (LOINC if possible) index: 3 comments: Key metadata element describing the document, used in searching/filtering. type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.type} isSummary: true created: isModifier: false short: Document creation time index: 8 comments: Creation time is used for tracking, organizing versions and searching. This is the creation time of the document, not the source material on which it is based. type: dateTime mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.created} isSummary: true author: isModifier: false short: Who and/or what authored the document index: 5 comments: Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant). type: Reference mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.author} isSummary: true masterIdentifier: isModifier: false short: Master Version Specific Identifier index: 0 comments: CDA Document Id extension and root. type: Identifier mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.masterIdentifier} isSummary: true custodian: isModifier: false short: Organization which maintains the document index: 6 comments: Identifies the logical organization to go to find the current version, where to report issues, etc. This is different from the physical location of the document, which is the technical location of the document, which host may be delegated to the management of some other organization. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.custodian} isSummary: true status: isModifier: true short: current | superseded | entered-in-error index: 10 comments: This is the status of the DocumentReference object, which might be independent from the docStatus element. type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.status} isSummary: true class: isModifier: false short: Categorization of document index: 4 comments: This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)). type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.class} isSummary: true identifier: isModifier: false short: Other identifiers for the document index: 1 type: Identifier mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.identifier} isSummary: true relatesTo: isModifier: true short: Relationships to other documents index: 12 type: BackboneElement mustSupport: false array: true elements: code: isModifier: false short: replaces | transforms | signs | appends index: 13 comments: If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. type: code mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.relatesTo.code} isSummary: true target: isModifier: false short: Target of the relationship index: 14 type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.relatesTo.target} isSummary: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.relatesTo} required: [target, code] isSummary: true context: isModifier: false short: Clinical context of document index: 20 comments: These values are primarily added to help with searching for interesting/relevant documents. type: BackboneElement mustSupport: false elements: encounter: isModifier: false short: Context of the document content type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.encounter} isSummary: true index: 21 event: isModifier: false short: Main Clinical Acts Documented index: 22 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. type: CodeableConcept mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.context.event} isSummary: true period: isModifier: false short: Time of service that is being documented type: Period mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.period} isSummary: true index: 23 facilityType: isModifier: false short: Kind of facility where patient was seen type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.facilityType} isSummary: true index: 24 practiceSetting: isModifier: false short: Additional details about where the content was created (e.g. clinical specialty) index: 25 comments: 'The value set for this content has an example binding because it is a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR and XDM for Direct Messaging Specification, Version 1), as well as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * XDS Connect-a-thon practiceSettingCode.' type: CodeableConcept mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.practiceSetting} isSummary: true sourcePatientInfo: isModifier: false short: Patient demographics from source type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.sourcePatientInfo} isSummary: true index: 26 related: isModifier: false short: Related identifiers or resources index: 27 comments: May be identifiers or resources that caused the DocumentReference or referenced Document to be created. type: BackboneElement mustSupport: false array: true elements: identifier: isModifier: false short: Identifier of related objects or events index: 28 comments: Order numbers, accession numbers, XDW workflow numbers. type: Identifier mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.related.identifier} isSummary: true ref: isModifier: false short: Related Resource index: 29 comments: Order, DiagnosticOrder, Procedure, EligibilityRequest, etc. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context.related.ref} isSummary: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.context.related} isSummary: true maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.context} isSummary: true securityLabel: isModifier: false short: Document security-tags index: 16 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. type: CodeableConcept mustSupport: false array: true maxLength: 0 base: {max: '*', min: 0, path: DocumentReference.securityLabel} isSummary: true subject: isModifier: false short: Who/what is the subject of the document type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.subject} isSummary: true index: 2 authenticator: isModifier: false short: Who/what authenticated the document index: 7 comments: 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. type: Reference mustSupport: false maxLength: 0 base: {max: '1', min: 0, path: DocumentReference.authenticator} isSummary: true package_version: 1.4.0 class: resource kind: resource url: http://hl7.org/fhir/StructureDefinition/DocumentReference base: http://hl7.org/fhir/StructureDefinition/DomainResource version: null required: [indexed, status, content, type]