DocumentReference FHIR Resource Proposal

DocumentReference

Owning committee name

IHE IT Infrastructure Technical Committee

Contributing or Reviewing Work Groups

• EHR

FHIR Resource Development Project Insight ID

unclear how to reference external organization ownership

Scope of coverage

This resource includes a set of metadata about a patient specific medical 'document'. This document might be CDA based, or might be of some other format including DICOM and PDF. The metadata that describes the 'document' is not a replacement for the document. This resource contained metadata is descriptive of the document provenance, patient identity, security & privacy, content format, content purpose, and document lifecycle.

RIM scope

This resource is not directly related to the RIM, but will leverage RIM concepts as appropriate.

Resource appropriateness

A reference to a document.

A document reference is a reference to a document defined in some other format, or stored in some other system. Typically, Document Reference Resources are used in document indexing systems, such as IHE XDS (see the XDS specific profile), and also to refer to:

• CDA documents in FHIR systems
• FHIR documents stored in other systems
• PDF documents
• DICOM structured reports stored in PACS
• Other kinds of documents, such as records of prescriptions.

FHIR defines both a document format and this document reference. FHIR documents are for documents that are authored and assembled in FHIR. This resource is for general references to other documents.

Note that there is no formal or limited definition of what a document is.

The document that is a target of the reference can be a reference to a FHIR document served by another server, or the target can be stored in the special FHIR Binary Resource, or the target can be stored on some other server system. The document reference is also able to address documents that are retrieved by a service call such as an XDS.b RetrieveDocumentSet, or a DICOM exchange, or a v2 message query, though the way each of these works must be specified in an implementation guide.

Content sources

• IHE Cross-Enterprise Document Sharing (XDS)
• IHE Cross-Community Document Access (XCA)
• IHE Cross-Enterprise Document Reliable Interchange (XDR)
• IHE Cross-Enterprise Document Media Interchange (XDM)
• IHE Mobile access to Health Documents {MHD}
• Dublin Core - Abstract Model
• RFC 5013 The Dublin Core Metadata Element Set
• ISO15836 Information and documentation -- The Dublin Core metadata element set

Example Scenarios

• submit a new document and metadata from the mobile device to a document receiver,
• get the metadata for an identified document,
• find document entries containing metadata based on query parameters, and
• retrieve a copy of a specific document.

Resource Relationships

unknown at this time

Timelines

urgent

gForge Users

john_moehrke