DocumentReference
FoundationA 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.
| Path | Card. | Type | Description & Constraints |
|---|---|---|---|
| DocumentReference | 0..* | — | A reference to a document |
| .idΣ | 0..1 | String | Logical id of this artifact |
| .metaΣ | 0..1 | Meta | Metadata about the resource |
| .implicitRules?!Σ | 0..1 | uri | A set of rules under which this content was created |
| .language | 0..1 | code | Language of the resource content Bindinglanguages(preferred) |
| .text | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| .contained | 0..* | Resource | Contained, inline Resources |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?! | 0..* | Extension | Extensions that cannot be ignored |
| .masterIdentifierΣ | 0..1 | Identifier | Master Version Specific Identifier |
| .identifierΣ | 0..* | Identifier | Other identifiers for the document |
| .status?!Σ | 1..1 | code | current | superseded | entered-in-error Bindingdocument-reference-status(required) |
| .docStatusΣ | 0..1 | code | preliminary | final | amended | entered-in-error Bindingcomposition-status(required) |
| .typeΣ | 0..1 | CodeableConcept | Kind of document (LOINC if possible) Bindingc80-doc-typecodes(preferred) |
| .categoryΣ | 0..* | CodeableConcept | Categorization of document Bindingdocument-classcodes(example) |
| .subjectΣ | 0..1 | Reference(Patient | Practitioner | Group | Device) | Who/what is the subject of the document |
| .dateΣ | 0..1 | instant | When this document reference was created |
| .authorΣ | 0..* | Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) | Who and/or what authored the document |
| .authenticator | 0..1 | Reference(Practitioner | PractitionerRole | Organization) | Who/what authenticated the document |
| .custodian | 0..1 | Reference(Organization) | Organization which maintains the document |
| .relatesToΣ | 0..* | BackboneElement | Relationships to other documents |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .codeΣ | 1..1 | code | replaces | transforms | signs | appends Bindingdocument-relationship-type(required) |
| .targetΣ | 1..1 | Reference(DocumentReference) | Target of the relationship |
| .descriptionΣ | 0..1 | string | Human-readable description |
| .securityLabelΣ | 0..* | CodeableConcept | Document security-tags Bindingsecurity-labels(extensible) |
| .contentΣ | 1..* | BackboneElement | Document referenced |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .attachmentΣ | 1..1 | Attachment | Where to access the document |
| .formatΣ | 0..1 | Coding | Format/content rules for the document Bindingformatcodes(preferred) |
| .contextΣ | 0..1 | BackboneElement | Clinical context of document |
| .id | 0..1 | String | Unique id for inter-element referencing |
| .extension | 0..* | Extension | Additional content defined by implementations |
| .modifierExtension?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
| .encounter | 0..* | Reference(Encounter | EpisodeOfCare) | Context of the document content |
| .event | 0..* | CodeableConcept | Main clinical acts documented Bindingv3-ActCode(example) |
| .periodΣ | 0..1 | Period | Time of service that is being documented |
| .facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Bindingc80-facilitycodes(example) |
| .practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Bindingc80-practice-codes(example) |
| .sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source |
| .related | 0..* | Reference(Resource) | Related identifiers or resources |