http://hl7.org/fhir/StructureDefinition/DocumentReference|5.0.0

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.
NameFlagsCardTypeDescription & Constraints
DocumentReference
0..*A reference to a document
 
identifier
Σ
0..*IdentifierBusiness identifiers for the document
 
version
Σ
0..1stringAn explicitly assigned identifer of a variation of the content in the DocumentReference
 
basedOn
0..*ReferenceProcedure that caused this media to be created
 
status *
?!Σ
1..1codecurrent | superseded | entered-in-error DocumentReferenceStatus (required)
 
docStatus
Σ
0..1coderegistered | partial | preliminary | final | amended | corrected | appended | cancelled | entered-in-error | deprecated | unknown ReferredDocumentStatus (required)
 
modality
Σ
0..*CodeableConceptImaging modality used ImagingModality (extensible)
 
type
Σ
0..1CodeableConceptKind of document (LOINC if possible) DocumentType (preferred)
 
category
Σ
0..*CodeableConceptCategorization of document ReferencedItemCategory (example)
 
subject
Σ
0..1ReferenceWho/what is the subject of the document
 
context
0..*ReferenceContext of the document content
 
event
0..*CodeableReferenceMain clinical acts documented DocumentEventType (example)
 
bodySite
Σ
0..*CodeableReferenceBody part included BodySite (example)
 
facilityType
0..1CodeableConceptKind of facility where patient was seen DocumentC80FacilityType (example)
 
practiceSetting
0..1CodeableConceptAdditional details about where the content was created (e.g. clinical specialty) DocumentC80PracticeSetting (example)
 
period
Σ
0..1PeriodTime of service that is being documented
 
date
Σ
0..1instantWhen this document reference was created
 
author
Σ
0..*ReferenceWho and/or what authored the document
 
attester
0..*BackboneElementAttests to accuracy of the document
 
 
mode *
1..1CodeableConceptpersonal | professional | legal | official DocumentAttestationMode (preferred)
 
 
time
0..1dateTimeWhen the document was attested
 
 
party
0..1ReferenceWho attested the document
 
custodian
0..1ReferenceOrganization which maintains the document
 
relatesTo
Σ
0..*BackboneElementRelationships to other documents
 
 
code *
Σ
1..1CodeableConceptThe relationship type with another document DocumentRelationshipType (extensible)
 
 
target *
Σ
1..1ReferenceTarget of the relationship
 
description
Σ
0..1markdownHuman-readable description
 
securityLabel
Σ
0..*CodeableConceptDocument security-tags SecurityLabels (example)
 
content *
Σ
1..*BackboneElementDocument referenced
 
 
attachment *
Σ
1..1AttachmentWhere to access the document
 
 
profile
Σ
0..*BackboneElementContent profile rules for the document
 
 
 
value[x] *
Σ
1..1Code|uri|canonical DocumentFormat (preferred)
 
 
 
 
valueCoding *
Σ
1..1Coding DocumentFormat (preferred)
 
 
 
 
valueUri *
Σ
1..1uri DocumentFormat (preferred)
 
 
 
 
valueCanonical *
Σ
1..1canonical DocumentFormat (preferred)