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 and updating documents. For fields supported on write or update operations, see the appropriate tasks for this resource.

This resource supports the following HL7 FHIR US Core Implementation Guide STU 4.0.0 profile:

• US Core DocumentReference Profile

The following fields are returned if valued for clinical documents:

• DocumentReference id

• Status

• Document status

• Document type

• Document category

• Subject (Patient)

• Created Date

• Author

  • Reference (Practitioner)

• Authenticator/verifying provider

• Document Attachment

  • Attachment ContentType

  • Created date/time

  • Title

  • URL (fully qualified link to the document)

• Document Format

• Patient encounter

  • Reference (Encounter)

• Document period

• Custodian

• Related

Terminology Bindings

• DocumentReference.status

  Description: The status of the document reference.

  Details: DocumentReference status

  System: http://hl7.org/fhir/document-reference-status

• DocumentReference.docStatus

  Description: The status of the underlying document.

  Details: DocumentReference docStatus

  System: http://hl7.org/fhir/r4/codesystem-composition-status.html

• DocumentReference.type

  Description: Specifies the particular type of document referenced.

  • Details: US Core DocumentReference Type

    System: http://loinc.org

  • Details: US Core DocumentReference Type

    System: http://terminology.hl7.org/CodeSystem/v3-NullFlavor (when type doesn't have a LOINC code)

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

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

• DocumentReference.category

  Description: A categorization for the type of document referenced.

  • Details: US Core DocumentReference Category

    System: http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category

  • Details: US Core DiagnosticReport Category

    System: http://loinc.org