DocumentReference

Terminology Bindings

DocumentReference.type
  • Description
    • Precise type of clinical document.
  • LOINC
    • Supported Values
      • 34840-9 - Rheumatology Note
      • 68608-9 - Summary Note

Create

Create new documents. Currently limited to unstructured clinical notes or documentation. For example, a document with display formatting or styling can be written, but a CCD cannot.

POST /DocumentReference

Headers

To successfully POST a document, the following headers must be provided. Document creation is supported from the closed endpoint only.

Content-Type: application/json+fhir
Authorization: <OAuth2 Bearer Token>

Body fields

Implementation Notes

Name Required Cardinality Type
resourceType Yes 1..1 string
  • Description
    • The type of the FHIR resource
  • Example
    • DocumentReference
  • Notes
    • resourceType must be DocumentReference
subject Yes 0..1 Reference (Patient)
  • Description
    • Who or what is the subject of the document.
  • Example
    • {
        "reference": "Patient/1234"
      }
      
type Yes 1..1 CodeableConcept
  • Description
    • Kind of document.
  • Example
    • {
        "coding": [
          {
            "system": "http://loinc.org",
            "code": "34840-9"
          }
        ]
      }
      
  • Notes
    • The type must include a loinc coding.
author No 0..1 Reference (Practitioner)
  • Description
    • Who and/or what authored the document
  • Example
    • {
        "author": [
          {
            "reference": "Practitioner/2150097"
          }
        ]
      }
      
  • Notes
    • If author is not provided, the author will be determined based on the access token.
indexed Yes 1..1 instant
  • Description
    • When this document reference was created
  • Example
    • {
        "indexed": "2015-05-16T091014Z"
      }
      
status Yes 1..1 code
  • Description
    • The status of this document reference
  • Example
    • {
        "status": "current"
      }
      
  • Notes
    • Currently support current only
docStatus No 0..1 CodeableConcept
  • Description
    • The status of underlying document
  • Example
    • {
        "status": "final"
      }
      
  • Notes
    • Currently support final and preliminary
description No 0..1 string
  • Description
    • Human-readable description (title)
  • Example
    • {
        "description": "Rheumatology Note"
      }
      
content Yes 1..* BackboneElement
  • Description
    • The referenced document
content.attachment Yes 1..1 Attachment
  • Description
    • An array of document contents. Must contain exactly 1 attachment.
  • Example
    • {
        "content": [
          {
            "attachment": {
              "contentType": "application/xhtml+xml;charset=utf-8",
              "data": "snipped"
            }
          }
        ]
      }
      
content.attachment.contentType Yes 0..1 string
  • Description
    • Mime type of the content, with charset etc.
  • Example
    • {
        "content": [
          {
            "attachment": {
              "contentType": "application/xhtml+xml;charset=utf-8"
            }
          }
        ]
      }
      
  • Notes
    • contentType must be 'application/xhtml+xml;charset=utf-8'
content.attachment.data Yes 0..1 string
  • Description
    • Data inline, base64 encoded XHTML.
  • Example
    • {
        "content": [
          {
            "attachment": {
              "data": "PCFET0NUWVBFIGh0bWwNCiAgU1lTVEVNI...snipped"
            }
          }
        ]
      }
      
  • Notes
    • You can validate your document using any available XHTML validator like the one linked here. Some sanitization is run on provided XHMTL. For example: Applet, iframe, link, script, and style tags will be removed completely. Other tags (a, button, form, frame, frameset, input, object, option, select, textarea) may be removed but the text within will remain.
context Yes 0..1 BackboneElement
  • Description
    • The clinical context in which the document was prepared
context.encounter Yes 0..1 Reference (Encounter)
  • Description
    • Context of the document content
  • Example
    • {
        "context": {
          "encounter": {
            "reference": "Encounter/4208053"
          }
        }
      }
      
context.period No 0..1 Period
  • Description
    • When the documented service was performed.
  • Example
    • {
        "context": {
          "period" : {
            "end": "2015-08-20T09:10:14Z"
          }
        }
      }
      
  • Notes
    • If provided, the service time must be set to context.period.end. If not provided, the document will be stored with the indexed dateTime.

Example Body

{
  "resourceType": "DocumentReference",
  "subject": {
    "reference": "Patient/53663272"
  },
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "34840-9"
      }
    ]
  },
  "author": [
    {
      "reference": "Practitioner/21500981"
    }
  ],
  "indexed": "2015-11-18T18:00:00Z",
  "status": "current",
  "docStatus": {
    "coding": [
      {
        "system": "http://hl7.org/fhir/composition-status",
        "code": "final"
      }
    ]
  },
  "description": "Rheumatology Note",
  "content": [
    {
      "attachment": {
        "contentType": "application/xhtml+xml;charset=utf-8",
        "data": "<snipped for brevity>"
      }
    }
  ],
  "context": {
    "encounter": {
      "reference": "Encounter/4208059"
    },
    "period": {
      "end": "2015-08-20T09:10:14Z"
    }
  }
}

Response

Status: 201 Created
   Connection → Keep-Alive
   Content-Encoding → gzip
   Content-Length → 20
   Content-Type → text/html; charset=UTF-8
   Date → Wed, 06 Jan 2016 18:09:18 GMT
   Keep-Alive → timeout=15, max=100
   Status → 201 Created
   access-control-allow-methods → DELETE, GET, POST, PUT, OPTIONS, HEAD
   access-control-allow-origin → *
   access-control-expose-headers → ETag, Content-Location, Location, X-Request-Id, WWW-Authenticate, Date
   access-control-max-age → 0
   cache-control → no-cache
   location → https://fhir-ehr.sandboxcerner.com/dstu2/0b8a0111-e8e6-4c26-a91c-5069cbc6b1ca/DocumentReference/5789254
   server-response-time → 5497.564885
   strict-transport-security → max-age=631152000
   vary → Origin,User-Agent,Accept-Encoding
   x-content-type-options → nosniff
   x-frame-options → SAMEORIGIN
   x-request-id → 9c7510c0-0bb5-4148-b37e-51a774c4091b
   x-runtime → 5.497541
   x-xss-protection → 1; mode=block

Operation: docref

Argonaut operation for querying DocumentReferences for the supplied parameters:

GET /DocumentReference/$docref?:parameters

Implementation Notes

Terminology Bindings

DocumentReference.type
  • Description
    • Precise type of clinical document.
  • LOINC
    • Supported Values
      • 34133-9 - Summary of episode note
DocumentReference.content.format

Parameters

Name Required? Type Description
patient Y reference A reference to the patient whose document references are required. Example: 14067892
type Y token The document reference type, can be a list of comma separated values. Example: http://loinc.org|34133-9
start N date The start of the date range from which document reference records should be included. If not provided, then all records from the beginning of time are included. Example: 2014-09-24T12:00:00.000Z
end N date The end of the date range till which document reference records should be included. If not provided, then all records up to the current date are included. Example: 2016-09-24T12:00:00.000Z

Notes:

Response

Status: 200 OK
GET: [...]/DocumentReference/$docref?patient=1316035&type=http://loinc.org|34133-9
{
  "resourceType": "Bundle",
  "id": "5d1a7f94-8ee4-45aa-bbe6-1dd087fba40c",
  "type": "searchset",
  "total": 1,
  "link": [
    {
      "relation": "self",
      "url": "https://fhir-open.sandboxcerner.com/dstu2/0b8a0111-e8e6-4c26-a91c-5069cbc6b1ca/DocumentReference/$docref?patient=1316035&type=http%3A%2F%2Floinc.org%7C34133-9"
    }
  ],
  "entry": [
    {
      "fullUrl": "https://fhir-open.sandboxcerner.com/dstu2/0b8a0111-e8e6-4c26-a91c-5069cbc6b1ca/DocumentReference/e6e34022-942c-42b9-a1e3-5452bb274627",
      "resource": {
        "resourceType": "DocumentReference",
        "id": "e6e34022-942c-42b9-a1e3-5452bb274627",
        "subject": {
          "reference": "Patient/1316035"
        },
        "type": {
          "coding": [
            {
              "system": "http://loinc.org",
              "code": "34133-9",
              "display": "Summary of episode note"
            }
          ],
          "text": "Summary of episode note"
        },
        "indexed": "2017-01-03T11:08:02-06:00",
        "status": "current",
        "content": [
          {
            "attachment": {
              "contentType": "application/xml",
              "url": "https://fhir-open.sandboxcerner.com/dstu2/0b8a0111-e8e6-4c26-a91c-5069cbc6b1ca/Binary/$autogen-ccd-if?patient=1316035"
            },
            "format": [
              {
                "system": "urn:oid:1.3.6.1.4.1.19376.1.2.3",
                "code": "urn:hl7-org:sdwg:ccda-structuredBody:1.1",
                "display": "For documents following C-CDA constraints using a structured body."
              }
            ]
          }
        ]
      }
    }
  ]
}