DocumentReference

This topic describes information for the DocumentReference resource.

To interact with the REST endpoints in the DocumentReference resource, see DocumentReference.

Overview

The DocumentReference resource is used to reference a clinical document for a patient within the health system. This resource supports reading Continuity of Care Documents (CCDs), returning a list of clinical documents, and a reference to retrieve a document as a PDF. When retrieving document links and metadata, this resource refers to the Binary resource for downloading the complete document.

Additionally, this resource supports writing an unstructured document. For fields supported on write, see the appropriate task for this resource.

The following fields are returned if valued for clinical documents:

• DocumentReference ID

• Subject

• Document type

• Document description/title

• Authenticator/verifying provider

• Create date/time

• Indexed date/time

• Status

• Document status

• Content

  • Attachment

• Content type

• URL

• Title

• Patient encounter

The following fields are returned if valued for the $docref operation (CCD read):

• DocumentReference ID

• Subject

• Document type

• Index date/time

• Status

• Format

• ContentType and URL

Terminology Bindings

• DocumentReference.type

  Description: The precise type of clinical document.

  • Details: LOINC Document Types

    System: http://loinc.org

  • Details: For more information, see Code Set 72 Clinical Event Codes under the List of Code Sets section in Proprietary Codes.

    System: https://fhir.cerner.com/<EHR_source_id>/codeSet/72