description: Base StructureDefinition for DocumentReference Resource package_name: hl7.fhir.r2.core name: DocumentReference type: null elements: indexed: {short: When this document reference created, comments: 'Referencing/indexing time is used for tracking, organizing versions and searching.', type: instant, isSummary: true, index: 9} description: {short: Human-readable description (title), 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, isSummary: true, index: 15} docStatus: {short: preliminary | final | appended | amended | entered-in-error, comments: The document that is pointed to might be in various lifecycle states., type: CodeableConcept, isSummary: true, index: 11} content: min: 1 short: Document referenced index: 17 type: BackboneElement array: true elements: attachment: {type: Attachment, short: Where to access the document, isSummary: true, index: 18} format: {short: Format/content rules for the document, comments: 'Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.', type: Coding, array: true, isSummary: true, index: 19} required: [attachment] isSummary: true type: {short: Kind of document (LOINC if possible), comments: 'Key metadata element describing the document, used in searching/filtering.', type: CodeableConcept, isSummary: true, index: 3} created: {short: Document creation time, 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, isSummary: true, index: 8} author: {short: Who and/or what authored the document, comments: Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant)., type: Reference, array: true, isSummary: true, index: 5} masterIdentifier: {short: Master Version Specific Identifier, comments: CDA Document Id extension and root., type: Identifier, isSummary: true, index: 0} custodian: {short: Organization which maintains the document, 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, isSummary: true, index: 6} status: {isModifier: true, short: current | superseded | entered-in-error, comments: 'This is the status of the DocumentReference object, which might be independent from the docStatus element.', type: code, isSummary: true, index: 10} class: {short: Categorization of document, comments: 'This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).', type: CodeableConcept, isSummary: true, index: 4} identifier: {type: Identifier, short: Other identifiers for the document, isSummary: true, array: true, index: 1} relatesTo: isModifier: true short: Relationships to other documents type: BackboneElement array: true isSummary: true index: 12 elements: code: {short: replaces | transforms | signs | appends, comments: 'If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.', type: code, isSummary: true, index: 13} target: {type: Reference, short: Target of the relationship, isSummary: true, index: 14} required: [target, code] context: short: Clinical context of document comments: These values are primarily added to help with searching for interesting/relevant documents. type: BackboneElement isSummary: true index: 20 elements: encounter: {type: Reference, short: Context of the document content, isSummary: true, index: 21} event: {short: Main Clinical Acts Documented, 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, array: true, isSummary: true, index: 22} period: {type: Period, short: Time of service that is being documented, isSummary: true, index: 23} facilityType: {short: Kind of facility where patient was seen, type: CodeableConcept, isSummary: true, index: 24} practiceSetting: {short: Additional details about where the content was created (e.g. clinical specialty), 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, isSummary: true, index: 25} sourcePatientInfo: {type: Reference, short: Patient demographics from source, isSummary: true, index: 26} related: short: Related identifiers or resources comments: May be identifiers or resources that caused the DocumentReference or referenced Document to be created. type: BackboneElement array: true isSummary: true index: 27 elements: identifier: {short: Identifier of related objects or events, comments: 'Order numbers, accession numbers, XDW workflow numbers.', type: Identifier, isSummary: true, index: 28} ref: {short: Related Resource, comments: 'Order, DiagnosticOrder, Procedure, EligibilityRequest, etc.', type: Reference, isSummary: true, index: 29} securityLabel: {short: Document security-tags, 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, array: true, isSummary: true, index: 16} subject: {type: Reference, short: Who/what is the subject of the document, isSummary: true, index: 2} authenticator: {short: Who/what authenticated the document, 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, isSummary: true, index: 7} package_version: 1.0.2 class: resource kind: resource url: http://hl7.org/fhir/StructureDefinition/DocumentReference version: null required: [indexed, status, content, type]