http://hl7.org/fhir/StructureDefinition/DocumentReference|4.0.1

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.
NameFlagsCardTypeDescription & Constraints
DocumentReference
0..*A reference to a document
 
masterIdentifier
Σ
0..1IdentifierMaster Version Specific Identifier
 
identifier
Σ
0..*IdentifierOther identifiers for the document
 
status *
?!Σ
1..1codecurrent | superseded | entered-in-error DocumentReferenceStatus (required)
 
docStatus
Σ
0..1codepreliminary | final | amended | entered-in-error ReferredDocumentStatus (required)
 
type
Σ
0..1CodeableConceptKind of document (LOINC if possible) DocumentC80Type (preferred)
 
category
Σ
0..*CodeableConceptCategorization of document DocumentC80Class (example)
 
subject
Σ
0..1ReferenceWho/what is the subject of the document
 
date
Σ
0..1instantWhen this document reference was created
 
author
Σ
0..*ReferenceWho and/or what authored the document
 
authenticator
0..1ReferenceWho/what authenticated the document
 
custodian
0..1ReferenceOrganization which maintains the document
 
relatesTo
Σ
0..*BackboneElementRelationships to other documents
 
 
code *
Σ
1..1codereplaces | transforms | signs | appends DocumentRelationshipType (required)
 
 
target *
Σ
1..1ReferenceTarget of the relationship
 
description
Σ
0..1stringHuman-readable description
 
securityLabel
Σ
0..*CodeableConceptDocument security-tags SecurityLabels (extensible)
 
content *
Σ
1..*BackboneElementDocument referenced
 
 
attachment *
Σ
1..1AttachmentWhere to access the document
 
 
format
Σ
0..1CodingFormat/content rules for the document DocumentFormat (preferred)
 
context
Σ
0..1BackboneElementClinical context of document
 
 
encounter
0..*ReferenceContext of the document content
 
 
event
0..*CodeableConceptMain clinical acts documented DocumentEventType (example)
 
 
period
Σ
0..1PeriodTime of service that is being documented
 
 
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)
 
 
sourcePatientInfo
0..1ReferencePatient demographics from source
 
 
related
0..*ReferenceRelated identifiers or resources