Document Reference

  • Version 3
  • Publié le
  • Mise à jour le

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.

Diagrammes connexes

Contraintes

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Stéréotypes

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Attributs

AttributTypeMultiplicitéNote sur l’attribut
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.

Relations

Classe d’origine Multiplicité d’origine Relation Classe de destination Multiplicité de destination
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..*

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Comment citer ce contenu:

Institut canadien d’information sur la santé. Document Reference. Consulté le 02 novembre 2026.

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