DocumentReference | Medplum

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 serialized object with a mime-type, so includes formal patient centric documents (CDA), clinical notes, scanned paper, and non-patient specific documents like policy text. Refer to the US Core DocumentReference profile.

Elements

Name	Required	Type	Description
masterIdentifier		Identifier	Master Version Specific Identifier Details Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document. CDA Document Id extension and root.
identifier		Identifier[]	Other identifiers for the document Details Other identifiers associated with the document, including version independent identifiers.
status	✓	code	current
docStatus		code	preliminary
type		CodeableConcept	Kind of document (LOINC if possible) Details Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced. Key metadata element describing the document that describes the exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.
category		CodeableConcept[]	Categorization of document Details A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type. Key metadata element describing the category or classification of the document. This is a primary key used in searching.
subject		Reference< Patient	Practitioner
date		instant	When this document reference was created Details When the document reference was created. Referencing/indexing time is used for tracking, organizing versions and searching.
author		Reference< Practitioner	PractitionerRole
authenticator		Reference< Practitioner	PractitionerRole
custodian		Reference< Organization >	Organization which maintains the document Details Identifies the organization or group who is responsible for ongoing maintenance of and access to the document. Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.
relatesTo		DocumentReferenceRelatesTo[]	Relationships to other documents Details Relationships that this document has with other document references that already exist. This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
id		string	Unique id for inter-element referencing Details Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
extension		Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension		Extension[]	Extensions that cannot be ignored even if unrecognized Details May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
code	✓	code	replaces
target	✓	Reference< DocumentReference >	Target of the relationship Details The target document of this relationship.
description		string	Human-readable description Details Human-readable description of the source document. What the document is about, a terse summary of the document.
securityLabel		CodeableConcept[]	Document security-tags Details A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to. 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.
content	✓	DocumentReferenceContent[]	Document referenced Details The document and format referenced. There may be multiple content element repetitions, each with a different format.

Search Parameters

Name	Type	Description	Expression
identifier	token	Master Version Specific Identifier	DocumentReference.masterIdentifier
patient	reference	Who/what is the subject of the document	DocumentReference.subject.where((resolve() is Patient))
type	token	Kind of document (LOINC if possible)	DocumentReference.type
encounter	reference	Context of the document content	DocumentReference.context.encounter
authenticator	reference	Who/what authenticated the document	DocumentReference.authenticator
author	reference	Who and/or what authored the document	DocumentReference.author
category	token	Categorization of document	DocumentReference.category
contenttype	token	Mime type of the content, with charset etc.	DocumentReference.content.attachment.contentType
custodian	reference	Organization which maintains the document	DocumentReference.custodian
date	date	When this document reference was created	DocumentReference.date
description	string	Human-readable description	DocumentReference.description
event	token	Main clinical acts documented	DocumentReference.context.event
facility	token	Kind of facility where patient was seen	DocumentReference.context.facilityType
format	token	Format/content rules for the document	DocumentReference.content.format
language	token	Human language of the content (BCP-47)	DocumentReference.content.attachment.language
location	uri	Uri where the data can be found	DocumentReference.content.attachment.url
period	date	Time of service that is being documented	DocumentReference.context.period
related	reference	Related identifiers or resources	DocumentReference.context.related
relatesto	reference	Target of the relationship	DocumentReference.relatesTo.target
relation	token	replaces	transforms
security-label	token	Document security-tags	DocumentReference.securityLabel
setting	token	Additional details about where the content was created (e.g. clinical specialty)	DocumentReference.context.practiceSetting
status	token	current	superseded
subject	reference	Who/what is the subject of the document	DocumentReference.subject
relationship	composite	Combination of relation and relatesTo	DocumentReference.relatesTo

Inherited Elements

Name	Type	Description
id	string	Logical id of this artifact Details The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
meta	Meta	Metadata about the resource Details The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
implicitRules	uri	A set of rules under which this content was created Details A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
language	code	Language of the resource content Details The base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
text	Narrative	Text summary of the resource, for human interpretation Details A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied).
contained	Resource[]	Contained, inline Resources Details These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
extension	Extension[]	Additional content defined by implementations Details May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
modifierExtension	Extension[]	Extensions that cannot be ignored Details May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.