DocumentReference

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.

These interaction paths describe standard FHIR R4 patterns. Availability can depend on the API capabilities enabled for your Ovok project.

Interaction	Method	Path
Read	GET	/fhir/R4/DocumentReference/[id]
Vread	GET	/fhir/R4/DocumentReference/[id]/_history/[vid]
Update	PUT	/fhir/R4/DocumentReference/[id]
Patch	PATCH	/fhir/R4/DocumentReference/[id]
Delete	DELETE	/fhir/R4/DocumentReference/[id]
Create	POST	/fhir/R4/DocumentReference
Search	GET	/fhir/R4/DocumentReference
History	GET	/fhir/R4/DocumentReference/[id]/_history

Top-level elements

Element	Type	Cardinality	Description
id	string	0..1	Logical id of this artifact
meta	Meta	0..1	Metadata about the resource
implicitRules	uri	0..1	A set of rules under which this content was created
language	code	0..1	Language of the resource content
text	Narrative	0..1	Text summary of the resource, for human interpretation
contained	Resource	0..*	Contained, inline Resources
extension	Extension	0..*	Additional content defined by implementations
modifierExtension	Extension	0..*	Extensions that cannot be ignored
masterIdentifier	Identifier	0..1	Master Version Specific Identifier
identifier	Identifier	0..*	Other identifiers for the document
status	code	1..1	current | superseded | entered-in-error
docStatus	code	0..1	preliminary | final | amended | entered-in-error
type	CodeableConcept	0..1	Kind of document (LOINC if possible)
category	CodeableConcept	0..*	Categorization of document
subject	Reference	0..1	Who/what is the subject of the document
date	instant	0..1	When this document reference was created
author	Reference	0..*	Who and/or what authored the document
authenticator	Reference	0..1	Who/what authenticated the document
custodian	Reference	0..1	Organization which maintains the document
relatesTo	BackboneElement	0..*	Relationships to other documents
description	string	0..1	Human-readable description
securityLabel	CodeableConcept	0..*	Document security-tags
content	BackboneElement	1..*	Document referenced
context	BackboneElement	0..1	Clinical context of document

Resource-specific search parameters

Parameter	Type	Description
authenticator	reference	Who/what authenticated the document
author	reference	Who and/or what authored the document
category	token	Categorization of document
contenttype	token	Mime type of the content, with charset etc.
custodian	reference	Organization which maintains the document
date	date	When this document reference was created
description	string	Human-readable description
encounter	reference	Multiple Resources: Composition: Context of the Composition ; DeviceRequest: Encounter during which request was created ; DiagnosticReport: The Encounter when the order was made ; DocumentReference: Context of the document content ; Flag: Alert relevant during encounter ; List: Context in which list created ; NutritionOrder: Return nutrition orders with this encounter identifier ; Observation: Encounter related to the observation ; Procedure: Encounter created as part of ; RiskAssessment: Where was assessment performed? ; ServiceRequest: An encounter in which this request is made ; VisionPrescription: Return prescriptions with this encounter identifier
event	token	Main clinical acts documented
facility	token	Kind of facility where patient was seen
format	token	Format/content rules for the document
identifier	token	Multiple Resources: AllergyIntolerance: External ids for this item ; CarePlan: External Ids for this plan ; CareTeam: External Ids for this team ; Composition: Version-independent identifier for the Composition ; Condition: A unique identifier of the condition record ; Consent: Identifier for this record (external references) ; DetectedIssue: Unique id for the detected issue ; DeviceRequest: Business identifier for request/order ; DiagnosticReport: An identifier for the report ; DocumentManifest: Unique Identifier for the set of documents ; DocumentReference: Master Version Specific Identifier ; Encounter: Identifier(s) by which this encounter is known ; EpisodeOfCare: Business Identifier(s) relevant for this EpisodeOfCare ; FamilyMemberHistory: A search by a record identifier ; Goal: External Ids for this goal ; ImagingStudy: Identifiers for the Study, such as DICOM Study Instance UID and Accession number ; Immunization: Business identifier ; List: Business identifier ; MedicationAdministration: Return administrations with this external identifier ; MedicationDispense: Returns dispenses with this external identifier ; MedicationRequest: Return prescriptions with this external identifier ; MedicationStatement: Return statements with this external identifier ; NutritionOrder: Return nutrition orders with this external identifier ; Observation: The unique id for a particular observation ; Procedure: A unique identifier for a procedure ; RiskAssessment: Unique identifier for the assessment ; ServiceRequest: Identifiers assigned to this order ; SupplyDelivery: External identifier ; SupplyRequest: Business Identifier for SupplyRequest ; VisionPrescription: Return prescriptions with this external identifier
language	token	Human language of the content (BCP-47)
location	uri	Uri where the data can be found
patient	reference	Multiple Resources: AllergyIntolerance: Who the sensitivity is for ; CarePlan: Who the care plan is for ; CareTeam: Who care team is for ; ClinicalImpression: Patient or group assessed ; Composition: Who and/or what the composition is about ; Condition: Who has the condition? ; Consent: Who the consent applies to ; DetectedIssue: Associated patient ; DeviceRequest: Individual the service is ordered for ; DeviceUseStatement: Search by subject - a patient ; DiagnosticReport: The subject of the report if a patient ; DocumentManifest: The subject of the set of documents ; DocumentReference: Who/what is the subject of the document ; Encounter: The patient or group present at the encounter ; EpisodeOfCare: The patient who is the focus of this episode of care ; FamilyMemberHistory: The identity of a subject to list family member history items for ; Flag: The identity of a subject to list flags for ; Goal: Who this goal is intended for ; ImagingStudy: Who the study is about ; Immunization: The patient for the vaccination record ; List: If all resources have the same subject ; MedicationAdministration: The identity of a patient to list administrations for ; MedicationDispense: The identity of a patient to list dispenses for ; MedicationRequest: Returns prescriptions for a specific patient ; MedicationStatement: Returns statements for a specific patient. ; NutritionOrder: The identity of the person who requires the diet, formula or nutritional supplement ; Observation: The subject that the observation is about (if patient) ; Procedure: Search by subject - a patient ; RiskAssessment: Who/what does assessment apply to? ; ServiceRequest: Search by subject - a patient ; SupplyDelivery: Patient for whom the item is supplied ; VisionPrescription: The identity of a patient to list dispenses for
period	date	Time of service that is being documented
related	reference	Related identifiers or resources
relatesto	reference	Target of the relationship
relation	token	replaces | transforms | signs | appends
relationship	composite	Combination of relation and relatesTo
security-label	token	Document security-tags
setting	token	Additional details about where the content was created (e.g. clinical specialty)
status	token	current | superseded | entered-in-error
subject	reference	Who/what is the subject of the document
type	token	Multiple Resources: AllergyIntolerance: allergy | intolerance - Underlying mechanism (if known) ; Composition: Kind of composition (LOINC if possible) ; DocumentManifest: Kind of document set ; DocumentReference: Kind of document (LOINC if possible) ; Encounter: Specific type of encounter ; EpisodeOfCare: Type/class - e.g. specialist referral, disease management

Reference

Official FHIR R4 spec: DocumentReference.
Maturity: Trial Use 3 (FMM 3).