Document Reference
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. Includes formal patient-centric documents, clinical notes, scanned paper and documents such as policy text that are not specific to a patient.
A Document Reference is used to index a document, clinical note and other binary objects such as a photo, video or audio recording, including those resulting from diagnostic or care provision procedures, to make them available to a health care system.
Appears in
Constraints
n/a
Stereotype(s)
n/a
Attributes
| Attribute | Type | Multiplicity | Attribute note |
|---|---|---|---|
| Document Reference Identifier | Identifier | 0..* | A business identifier of the Document Reference, including a master identifier. |
| Document Reference Version | String | 0..1 | An explicitly assigned identifier of a variation of the content in the Document Reference. |
| Document Reference Status Code | Codeable Concept | 1 | Uniquely specifies the current state of the document reference.
Value Set: http://hl7.org/fhir/ValueSet/document-reference-status |
| Document Reference Document Status Code | Codeable Concept | 0..1 | Uniquely specifies the status of the underlying clinical document.
Value Set: http://hl7.org/fhir/ValueSet/composition-status |
| Document Reference Modality Code | Codeable Concept | 0..1 | Uniquely specifies an imaging modality used. This may include both acquisition and non-acquisition modalities.
Value Set: To be developed. |
| Document Reference Type Code | Codeable Concept | 0..1 | Uniquely specifies a particular kind of document referenced (e.g., history and physical, discharge summary, progress note).
Value Set: To be developed. |
| Document Reference Category Code | Codeable Concept | 0..1 | Uniquely specifies a categorization for the type of document referenced.
Value Set: To be developed. |
| Document Reference Service Period | Period | 0..1 | A time period of the service that is being documented. |
| Document Reference Date Time | Date Time | 0..1 | The date and time of the Document Reference creation. |
| Document Reference Description | String | 0..1 | A human-readable narrative description of the Document Reference. |
| Document Reference Practice Setting Code | Codeable Concept | 0..1 | Uniquely specifies the practice setting where the content was created, often reflecting the clinical specialty.
Value Set: To be developed. |
Relationships
| From class | From multiplicity | Relationship | To class | To multiplicity |
|---|---|---|---|---|
| Patient | 0..1 | subject of | Document Reference | 0..* |
| Device | 0..1 | has | Document Reference | 0..* |
| Patient Consent | 0..* | is | Document Reference | 0..* |
| Service Request Reason | 0..* | is | Document Reference | 0..1 |
| Procedure Reason | 0..* | is | Document Reference | 0..1 |
| Document Reference | 0..1 | context for | Episode Of Care Reason | 0..* |
| Health Concern Evidence | 0..* | supported by | Document Reference | 0..* |
| Document Reference | 0..1 | has | Document Party Role | 1..* |
| Document Reference | 0..* | has (aggregation) | Attachment | 0..* |
| Document Reference | 0..* | applies to | Clinical Document | 0..* |
| Document Reference | 0..* | has | Appointment | 0..* |
| Encounter Reason | 0..* | is | Document Reference | 0..1 |
| Encounter | 0..* | is context for | Document Reference | 0..* |
| Observation | 0..* | derived from | Document Reference | 0..* |
| Document Reference | 0..1 | relates to | Document Reference | 0..* |
Contact us
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How to cite:
Canadian Institute for Health Information. Document Reference. Accessed November 02, 2026.
