A reference to a document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.

Usually, this is used for documents other than those defined by FHIR.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.

Additional notes that apply to this resource or element.

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

This cross version extension includes the FHIR R4 version of the Media.view field which has at this point in time (April 18, 2025), not yet been included in the extension pack.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Other business identifiers associated with the document, including version independent identifiers.

The structure and format of this identifier would be consistent with the specification corresponding to the format of the document. (e.g. for a DICOM standard document, a 64-character numeric UID; for an HL7 CDA format, the CDA Document Id root and extension).

Document identifiers usually assigned by the source of the document, or other business identifiers such as XDS DocumentEntry.uniqueId and DocumentEntry.entryUUID. These identifiers are specific to this instance of the document.

The status of this document reference.

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

The status of the document reference.

Imaging modality used. This may include both acquisition and non-acquisition modalities.

Type of acquired data in the instance.

Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

Precise type of clinical document.

Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

Describes the clinical encounter or type of care that the document content is associated with.

The time period over which the service that is described by the document was provided.

Identifies who is responsible for adding the information to the document.

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata.

content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The document or URL of the document along with critical metadata to prove content has integrity.

A reference to a document of any kind for any purpose. While the term “document” implies a more narrow focus, for this resource this "document" encompasses any serialized object with a mime-type, it includes formal patient-centric documents (CDA), clinical notes, scanned paper, non-patient specific documents like policy text, as well as a photo, video, or audio recording acquired or used in healthcare. The DocumentReference resource provides metadata about the document so that the document can be discovered and managed. The actual content may be inline base64 encoded data or provided by direct reference.

Usually, this is used for documents other than those defined by FHIR.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Within the context of the FHIR RESTful interactions, the resource has an id except for cases like the create and conditional update. Otherwise, the use of the resouce id depends on the given use case.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of its narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

IETF language tag for a human language

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have a narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, nor can they have their own independent transaction scope. This is allowed to be a Parameters resource if and only if it is referenced by a resource that provides context/meaning.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags in their meta elements, but SHALL NOT have security labels.

An Extension

Additional notes that apply to this resource or element.

This extension SHALL NOT be used if the resource already has standard 'note' element (or equivalent) of type Annotation on the same element

This cross version extension includes the FHIR R4 version of the Media.view field which has at this point in time (April 18, 2025), not yet been included in the extension pack.

May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Other business identifiers associated with the document, including version independent identifiers.

The structure and format of this identifier would be consistent with the specification corresponding to the format of the document. (e.g. for a DICOM standard document, a 64-character numeric UID; for an HL7 CDA format, the CDA Document Id root and extension).

Document identifiers usually assigned by the source of the document, or other business identifiers such as XDS DocumentEntry.uniqueId and DocumentEntry.entryUUID. These identifiers are specific to this instance of the document.

An explicitly assigned identifer of a variation of the content in the DocumentReference.

While each resource, including the DocumentReference itself, has its own version identifier, this is a formal identifier for the logical version of the DocumentReference as a whole. It would remain constant if the resources were moved to a new server, and all got new individual resource versions, for example.

A procedure that is fulfilled in whole or in part by the creation of this media.

Allows tracing of authorization for the event and tracking whether proposals/recommendations were acted upon.

The status of this document reference.

This is the status of the DocumentReference object, which might be independent from the docStatus element.

This element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.

The status of the document reference.

The status of the underlying document.

The document that is pointed to might be in various lifecycle states.

Status of the underlying document.

Imaging modality used. This may include both acquisition and non-acquisition modalities.

Type of acquired data in the instance.

Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.

Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.

Precise type of clinical document.

A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.

High-level kind of document at a macro level.

Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

Describes the clinical encounter or type of care that the document content is associated with.

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.

This list of codes represents the main clinical acts being documented.

The anatomic structures included in the document.

SNOMED CT Body site concepts

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

A reference to a concept - e.g. the information is identified by its general class to the degree of precision found in the terminology.

A reference to a resource the provides exact details about the information being referenced.

The kind of facility where the patient was seen.

XDS Facility Type.

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC.

Additional details about where the content was created (e.g. clinical specialty).

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

The time period over which the service that is described by the document was provided.

When the document reference was created.

Referencing/indexing time is used for tracking, organizing versions and searching.

Identifies who is responsible for adding the information to the document.

Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).

A participant who has authenticated the accuracy of the document.

Only list each attester once.

Identifies responsibility for the accuracy of the document content.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of attestation the authenticator offers.

The way in which a person authenticated a document.

Indicates the level of authority of the attestation.

When the document was attested by the party.

Identifies when the information in the document was deemed accurate. (Things may have changed since then.).

Who attested the document in the specified way.

Identifies who has taken on the responsibility for accuracy of the document content.

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.

Relationships that this document has with other document references that already exist.

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of relationship that this document has with anther document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The type of relationship between the documents.

The target document of this relationship.

Human-readable description of the source document.

What the document is about, a terse summary of the document.

Helps humans to assess whether the document is of interest.

A set of Security-Tag codes specifying the level of privacy/security of the Document found at DocumentReference.content.attachment.url. Note that DocumentReference.meta.security contains the security labels of the data elements in DocumentReference, while DocumentReference.securityLabel contains the security labels for the document the reference refers to. The distinction recognizes that the document may contain sensitive information, while the DocumentReference is metadata about the document and thus might not be as sensitive as the document. For example: a psychotherapy episode may contain highly sensitive information, while the metadata may simply indicate that some episode happened.

The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce.

In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.

Example Security Labels from the Healthcare Privacy and Security Classification System.

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

The document and format referenced. If there are multiple content element repetitions, these must all represent the same document in different format, or attachment metadata.

content element shall not contain different versions of the same content. For version handling use multiple DocumentReference with .relatesTo.

Note that .relatesTo may also include references to other DocumentReference with a transforms relationship to represent the same document in multiple formats.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The document or URL of the document along with critical metadata to prove content has integrity.

An identifier of the document constraints, encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Note that IHE often issues URNs for formatCode codes, not all documents can be identified by a URI.

For FHIR content, .profile should indicate the structureDefinition profile canonical URI(s) that the content complies with.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and managable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Code|uri|canonical.

Document Format Codes.