Implementation Guide
23.1.0 - R4 APIs
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Official URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile | Version: 23.1.0 | |||
Active as of 2022-03-01 | Computable Name: AthenaDocumentReference |
athena documentref profile
This DocumentReference profile is part of the set of resource profiles supported by the API Server used with the athenaPractice and athenaFlow products. It further describes read, search, create and update capabilities of these products.
This profile is used to define the content that will be returned by the API Server in response to requests to access DocumentReference resources. All elements listed in the differential profile view are Supported, which means that the API Server is capable of supplying these fields from the product database when they have been populated via the product or its APIs.
The profile also defines the content that must be supplied to the API Server in response to requests to populate DocumentReference resources. Fields which are marked as Mandatory in this profile are those that must be supplied to the API Server in content used to populate a resource.
The DocumentReference resource is used to access or create documents related to the patient. Content of the resource derives from the DOCUMENT table in athenaPractice and athenaFlow, and the PatientProfileAttachment and PatietVisitAttachment tables in athenaPractice. Specific detail can be found in the Mappings tab in the profile detail page.
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | S | 0..1 | id | Logical id of this artifact |
meta | 0..1 | Meta | Metadata about the resource | |
lastUpdated | 0..1 | instant | When the resource version last changed | |
Slices for profile | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri | |
profile:us-core-documentreference | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | |
profile:athena-documentref-profile | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile | |
Slices for security | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding | |
security:SENSITIVECHART | 0..1 | Coding | Security Labels applied to this resource | |
security:CONFABBR | 0..1 | Coding | Security Labels applied to this resource | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
Slices for tag | Content/Rules for all slices | |||
tag:CHANGE | 1..2 | Coding | Tags applied to this resource | |
Slices for extension | Content/Rules for all slices | |||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |
value[x] | 1..1 | dateTime | Value of extension | |
masterIdentifier | 0..1 | Identifier | Master Version Specific Identifier | |
identifier | S | 0..1 | Identifier | Other identifiers for the document |
status | S | 1..1 | code | current | superseded | entered-in-error |
docStatus | 0..1 | code | preliminary | final | amended | entered-in-error | |
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) |
category | S | 1..* | CodeableConcept | Categorization of document |
subject | S | 1..1 | Reference(Patient) | Who/what is the subject of the document |
date | S | 0..1 | instant | When this document reference was created |
author | S | 0..* | Reference(Practitioner) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document |
relatesTo | S | 0..* | BackboneElement | Relationships to other documents |
code | S | 1..1 | code | replaces | transforms | signs | appends |
target | 1..1 | Reference(DocumentReference) | Target of the relationship | |
description | 0..1 | string | Human-readable description | |
Slices for content | S | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use |
content:InternalAttachment | S | 0..1 | BackboneElement | Document referenced |
content:InternalAttachment2 | S | 0..1 | BackboneElement | Document referenced |
content:InternalAttachment3 | S | 0..1 | BackboneElement | Document referenced |
content:ExternalAttachment | S | 0..1 | BackboneElement | Document referenced |
content:DataAbsentReason | 0..1 | BackboneElement | Document referenced | |
context | S | 0..1 | BackboneElement | Clinical context of document |
encounter | S | 0..1 | Reference(Encounter) | Context of the document content |
period | S | 0..1 | Period | Time of service that is being documented |
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen | |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) | |
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |
Documentation for this format |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | SΣ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
lastUpdated | Σ | 0..1 | instant | When the resource version last changed |
Slices for profile | Σ | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri |
profile:us-core-documentreference | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference |
profile:athena-documentref-profile | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile |
Slices for security | Σ | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
security:SENSITIVECHART | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
security:CONFABBR | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
Slices for tag | Content/Rules for all slices | |||
tag:CHANGE | Σ | 1..2 | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |
value[x] | 1..1 | dateTime | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier |
identifier | SΣ | 0..1 | Identifier | Other identifiers for the document |
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. |
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. |
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document |
date | SΣ | 0..1 | instant | When this document reference was created |
author | SΣ | 0..* | Reference(Practitioner) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document |
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. |
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship |
description | Σ | 0..1 | string | Human-readable description |
Slices for content | SΣ | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use |
content:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment2 | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment3 | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:ExternalAttachment | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:DataAbsentReason | Σ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
context | SΣ | 0..1 | BackboneElement | Clinical context of document |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
encounter | S | 0..1 | Reference(Encounter) | Context of the document content |
period | SΣ | 0..1 | Period | Time of service that is being documented |
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.security:SENSITIVECHART | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.security:CONFABBR | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.tag:CHANGE | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | |
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
Slices for profile | Σ | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri | ||||
profile:us-core-documentreference | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | ||||
profile:athena-documentref-profile | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile | ||||
Slices for security | Σ | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
security:SENSITIVECHART | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
security:CONFABBR | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
Slices for tag | Content/Rules for all slices | |||||||
tag:CHANGE | Σ | 1..2 | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |||||
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |||||
value[x] | 1..1 | dateTime | Value of extension | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..1 | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner) | Who and/or what authored the document | ||||
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document | ||||
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document | ||||
relatesTo | SΣ | 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 | ||||
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
description | Σ | 0..1 | string | Human-readable description | ||||
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for content | SΣ | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use | ||||
content:All Slices | Content/Rules for all slices | |||||||
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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment2 | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment3 | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:ExternalAttachment | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:DataAbsentReason | Σ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
context | SΣ | 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 | S | 0..1 | Reference(Encounter) | Context of the document content | ||||
event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.security:SENSITIVECHART | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.security:CONFABBR | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag:CHANGE | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment2.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment3.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:ExternalAttachment.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:DataAbsentReason.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
This structure is derived from DocumentReference
Summary
Mandatory: 5 elements(9 nested mandatory elements)
Must-Support: 20 elements
Fixed: 3 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from DocumentReference
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | S | 0..1 | id | Logical id of this artifact |
meta | 0..1 | Meta | Metadata about the resource | |
lastUpdated | 0..1 | instant | When the resource version last changed | |
Slices for profile | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri | |
profile:us-core-documentreference | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | |
profile:athena-documentref-profile | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile | |
Slices for security | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding | |
security:SENSITIVECHART | 0..1 | Coding | Security Labels applied to this resource | |
security:CONFABBR | 0..1 | Coding | Security Labels applied to this resource | |
system | 1..1 | uri | Identity of the terminology system | |
code | 1..1 | code | Symbol in syntax defined by the system | |
Slices for tag | Content/Rules for all slices | |||
tag:CHANGE | 1..2 | Coding | Tags applied to this resource | |
Slices for extension | Content/Rules for all slices | |||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |
value[x] | 1..1 | dateTime | Value of extension | |
masterIdentifier | 0..1 | Identifier | Master Version Specific Identifier | |
identifier | S | 0..1 | Identifier | Other identifiers for the document |
status | S | 1..1 | code | current | superseded | entered-in-error |
docStatus | 0..1 | code | preliminary | final | amended | entered-in-error | |
type | S | 1..1 | CodeableConcept | Kind of document (LOINC if possible) |
category | S | 1..* | CodeableConcept | Categorization of document |
subject | S | 1..1 | Reference(Patient) | Who/what is the subject of the document |
date | S | 0..1 | instant | When this document reference was created |
author | S | 0..* | Reference(Practitioner) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document |
relatesTo | S | 0..* | BackboneElement | Relationships to other documents |
code | S | 1..1 | code | replaces | transforms | signs | appends |
target | 1..1 | Reference(DocumentReference) | Target of the relationship | |
description | 0..1 | string | Human-readable description | |
Slices for content | S | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use |
content:InternalAttachment | S | 0..1 | BackboneElement | Document referenced |
content:InternalAttachment2 | S | 0..1 | BackboneElement | Document referenced |
content:InternalAttachment3 | S | 0..1 | BackboneElement | Document referenced |
content:ExternalAttachment | S | 0..1 | BackboneElement | Document referenced |
content:DataAbsentReason | 0..1 | BackboneElement | Document referenced | |
context | S | 0..1 | BackboneElement | Clinical context of document |
encounter | S | 0..1 | Reference(Encounter) | Context of the document content |
period | S | 0..1 | Period | Time of service that is being documented |
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen | |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) | |
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |
Documentation for this format |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |
id | SΣ | 0..1 | id | Logical id of this artifact |
meta | Σ | 0..1 | Meta | Metadata about the resource |
lastUpdated | Σ | 0..1 | instant | When the resource version last changed |
Slices for profile | Σ | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri |
profile:us-core-documentreference | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference |
profile:athena-documentref-profile | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile |
Slices for security | Σ | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
security:SENSITIVECHART | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
security:CONFABBR | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. |
system | Σ | 1..1 | uri | Identity of the terminology system |
code | Σ | 1..1 | code | Symbol in syntax defined by the system |
Slices for tag | Content/Rules for all slices | |||
tag:CHANGE | Σ | 1..2 | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
Slices for extension | Content/Rules for all slices | |||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |
value[x] | 1..1 | dateTime | Value of extension | |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier |
identifier | SΣ | 0..1 | Identifier | Other identifiers for the document |
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. |
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. |
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. |
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. |
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document |
date | SΣ | 0..1 | instant | When this document reference was created |
author | SΣ | 0..* | Reference(Practitioner) | Who and/or what authored the document |
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document |
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document |
relatesTo | SΣ | 0..* | BackboneElement | Relationships to other documents |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. |
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship |
description | Σ | 0..1 | string | Human-readable description |
Slices for content | SΣ | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use |
content:All Slices | Content/Rules for all slices | |||
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment2 | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:InternalAttachment3 | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:ExternalAttachment | SΣ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
content:DataAbsentReason | Σ | 0..1 | BackboneElement | Document referenced |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
attachment | Σ | 1..1 | Attachment | Where to access the document |
context | SΣ | 0..1 | BackboneElement | Clinical context of document |
modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized |
encounter | S | 0..1 | Reference(Encounter) | Context of the document content |
period | SΣ | 0..1 | Period | Time of service that is being documented |
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |
Documentation for this format |
Path | Conformance | ValueSet | URI |
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.security:SENSITIVECHART | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.security:CONFABBR | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | |
DocumentReference.meta.tag:CHANGE | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | |
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | |
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | |
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | |
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | |
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | |
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | |
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
DocumentReference | 0..* | DocumentReference | A reference to a document | |||||
id | SΣ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
versionId | Σ | 0..1 | id | Version specific identifier | ||||
lastUpdated | Σ | 0..1 | instant | When the resource version last changed | ||||
source | Σ | 0..1 | uri | Identifies where the resource comes from | ||||
Slices for profile | Σ | 2..* | canonical() | Profiles this resource claims to conform to Slice: Unordered, Open by value:uri | ||||
profile:us-core-documentreference | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | ||||
profile:athena-documentref-profile | Σ | 1..1 | canonical() | Profiles this resource claims to conform to Fixed Value: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-profile | ||||
Slices for security | Σ | 0..2 | Coding | Security Labels applied to this resource Slice: Unordered, Open by value:coding Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
security:SENSITIVECHART | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
security:CONFABBR | Σ | 0..1 | Coding | Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
system | Σ | 1..1 | uri | Identity of the terminology system | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 1..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
Slices for tag | Content/Rules for all slices | |||||||
tag:CHANGE | Σ | 1..2 | Coding | Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones". | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
refprovid | 0..1 | Reference() | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-refprovid | |||||
pubtime | 0..1 | (Complex) | Extension URL: https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
url | 1..1 | uri | "https://docs.mydata.athenahealth.com/fhir-r4/StructureDefinition/athena-documentref-extension-pubtime" | |||||
value[x] | 1..1 | dateTime | Value of extension | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
masterIdentifier | Σ | 0..1 | Identifier | Master Version Specific Identifier | ||||
identifier | SΣ | 0..1 | Identifier | Other identifiers for the document | ||||
status | ?!SΣ | 1..1 | code | current | superseded | entered-in-error Binding: DocumentReferenceStatus (required): The status of the document reference. | ||||
docStatus | Σ | 0..1 | code | preliminary | final | amended | entered-in-error Binding: CompositionStatus (required): Status of the underlying document. | ||||
type | SΣ | 1..1 | CodeableConcept | Kind of document (LOINC if possible) Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. | ||||
category | SΣ | 1..* | CodeableConcept | Categorization of document Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. | ||||
subject | SΣ | 1..1 | Reference(Patient) | Who/what is the subject of the document | ||||
date | SΣ | 0..1 | instant | When this document reference was created | ||||
author | SΣ | 0..* | Reference(Practitioner) | Who and/or what authored the document | ||||
authenticator | S | 0..1 | Reference(Practitioner) | Who/what authenticated the document | ||||
custodian | S | 0..1 | Reference(Organization) | Organization which maintains the document | ||||
relatesTo | SΣ | 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 | ||||
code | SΣ | 1..1 | code | replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents. | ||||
target | Σ | 1..1 | Reference(DocumentReference) | Target of the relationship | ||||
description | Σ | 0..1 | string | Human-readable description | ||||
securityLabel | Σ | 0..* | CodeableConcept | Document security-tags Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System. | ||||
Slices for content | SΣ | 1..3 | BackboneElement | Document referenced Slice: Unordered, Open by value:type use | ||||
content:All Slices | Content/Rules for all slices | |||||||
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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment2 | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:InternalAttachment3 | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:ExternalAttachment | SΣ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
content:DataAbsentReason | Σ | 0..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 | ||||
attachment | Σ | 1..1 | Attachment | Where to access the document | ||||
format | Σ | 0..1 | Coding | Format/content rules for the document Binding: DocumentReferenceFormatCodeSet (preferred): Document Format Codes. | ||||
context | SΣ | 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 | S | 0..1 | Reference(Encounter) | Context of the document content | ||||
event | 0..* | CodeableConcept | Main clinical acts documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented. | |||||
period | SΣ | 0..1 | Period | Time of service that is being documented | ||||
facilityType | 0..1 | CodeableConcept | Kind of facility where patient was seen Binding: FacilityTypeCodeValueSet (example): XDS Facility Type. | |||||
practiceSetting | 0..1 | CodeableConcept | Additional details about where the content was created (e.g. clinical specialty) Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty). | |||||
sourcePatientInfo | 0..1 | Reference(Patient) | Patient demographics from source | |||||
related | 0..* | Reference(Resource) | Related identifiers or resources | |||||
Documentation for this format |
Path | Conformance | ValueSet | URI | |||
DocumentReference.meta.security | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.security:SENSITIVECHART | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.security:CONFABBR | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.meta.tag:CHANGE | example | CommonTagshttp://hl7.org/fhir/ValueSet/common-tags from the FHIR Standard | ||||
DocumentReference.language | preferred | CommonLanguages
http://hl7.org/fhir/ValueSet/languages from the FHIR Standard | ||||
DocumentReference.status | required | DocumentReferenceStatushttp://hl7.org/fhir/ValueSet/document-reference-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.docStatus | required | CompositionStatushttp://hl7.org/fhir/ValueSet/composition-status|4.0.1 from the FHIR Standard | ||||
DocumentReference.type | preferred | DocumentTypeValueSethttp://hl7.org/fhir/ValueSet/c80-doc-typecodes from the FHIR Standard | ||||
DocumentReference.category | example | DocumentClassValueSethttp://hl7.org/fhir/ValueSet/document-classcodes from the FHIR Standard | ||||
DocumentReference.relatesTo.code | required | DocumentRelationshipTypehttp://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 from the FHIR Standard | ||||
DocumentReference.securityLabel | extensible | All Security Labelshttp://hl7.org/fhir/ValueSet/security-labels from the FHIR Standard | ||||
DocumentReference.content.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment2.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:InternalAttachment3.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:ExternalAttachment.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.content:DataAbsentReason.format | preferred | DocumentReferenceFormatCodeSet (a valid code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem )http://hl7.org/fhir/ValueSet/formatcodes from the FHIR Standard | ||||
DocumentReference.context.event | example | ActCodehttp://terminology.hl7.org/ValueSet/v3-ActCode | ||||
DocumentReference.context.facilityType | example | FacilityTypeCodeValueSethttp://hl7.org/fhir/ValueSet/c80-facilitycodes from the FHIR Standard | ||||
DocumentReference.context.practiceSetting | example | PracticeSettingCodeValueSethttp://hl7.org/fhir/ValueSet/c80-practice-codes from the FHIR Standard |
This structure is derived from DocumentReference
Summary
Mandatory: 5 elements(9 nested mandatory elements)
Must-Support: 20 elements
Fixed: 3 elements
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron
Interactions supported by this resource are listed below.
Search parameters are executed as specified in the HL7 FHIR RESTful API implementation definition. To search for DocumentReference resources, an application shall perform an HTTP GET, specifying the query parameters associated with the resource.
GET [base]/fhir/r4/DocumentReference?{search-parameters}{&_count=[max-results]&_format=[json|xml]&_summary=[true|text|data]}
Where:
Name | Description |
---|---|
[base] | Specifies the base URL of the FHIR Server, e.g., https://apsandbox.fhirapi.athenahealth.com/demoAPIServer |
[_count] | Specifies the maximum number of search results to return in a single query. Note: The count of results does not limit the number of additional resources returned via the _include parameter. No more than max-results DocumentReference resources which match the search criteria will be returned. The API Server has default and maximum limits for the value that can be specified for this parameter. These limits may vary depending upon the client application vendors participation level in the Athenahealth Partner program. Note: The API Server support the HL7 FHIR Paging capability. |
[_format] | Specifies the format of the output and may be xml or json. When present, the _format value overrides the value of the Accept header in the request. |
[_summary] | Filters the output to include only narrative elements (_summary=text), summary elements (_summary=true) or to omit the generated narrative (_summary=data). Note: If the generated html narrative for the resource is not going to be used by the call, using _summary=data provides improved API response times, especially when returning larger result sets. |
_id (token) | The ID of the resource |
_lastUpdated (date) | |
_lastUpdated-fromnow (quantity) | Like _lastUpdated except expressed as a positive or negative offset from the current time in units of time, e.g. _lastUpdated-fromnow=ge7||d for more than seven days in the future or =le-2||mo for less than two months in the past. The unit must be specified. |
_security (token) | |
authenticator (reference) | Who/what authenticated the document |
author (reference) | Who and/or what authored the document |
category (token) | Categorization of document |
custodian (reference) | Organization which maintains the document |
description (string) | Human-readable description (title) |
encounter (reference) | Context of the document content |
facility (token) | Kind of facility where patient was seen |
identifier (token) | Master Version Specific Identifier |
date (date) | When this document reference created |
date-fromnow (quantity) | Like indexed except expressed as a positive or negative offset from the current time in units of time, e.g. indexed-fromnow=ge7||d for more than seven days in the future or =le-2||mo for less than two months in the past. The unit must be specified. |
patient (reference) | Who/what is the subject of the document |
period (date) | Time of service that is being documented |
period-fromnow (quantity) | Like period except expressed as a positive or negative offset from the current time in units of time, e.g. period-fromnow=ge7||d for more than seven days in the future or =le-2||mo for less than two months in the past. The unit must be specified. |
relatesto (reference) | Target of the relationship |
relation (token) | replaces | transforms | signs | appends |
status (token) | current | superseded | entered-in-error |
subject (reference) | Who/what is the subject of the document |
type (token) | Kind of document (LOINC if possible) |
includeContent(boolean) | Include a copy of Binary resources referenced by content.attachment elements in the response Bundle when includeContent is true. |
Note: Include a copy of Binary resources referenced by content.attachment elements in the response Bundle when includeContent is true. Example of DocumentReference with includeContent=true
DocumentReference ExampleThe following HTTP response codes are returned by this API call:
200 OK | The query was performed and any results found are contained within the body of the HTTP response. Note: The search API will return 200 OK when the query itself is successful, regardless of whether or not any matching results were found. |
401 Unauthorized | Authorization is required for this request, and either the Authorization header is missing or the supplied user credentials in the Authorization header are not valid or have expired. The body of the HTTP response will contain an OperationOutcome resource that indicates that Authorization is required. |
500 Server Error | The server may return other error codes to indicate other error conditions. The body of the HTTP response will contain an OperationOutcome resource that indicates the nature of the error. |