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DocumentReference Profile

Canonical../StructureDefinition/nexus-emr-core-documentreference
Statusdraft · 1.26.0
BaseDocumentReference (constraint)
CQL primary code pathtype — what this means
SourceFSH · JSON

Nexus EMR profile for an ATTACHED DOCUMENT -- a clinical document that exists as a file: scanned paper, incoming faxes, external consult letters received as PDF, signed consent forms, patient-uploaded files. FHIR holds the metadata and clinical context; the bytes live in document storage and are reached through content.attachment.url.

Examples

Allergy Consult Letter (challenge refuted) · Anemia Consultation Document · Cardiology Consult Letter (received) · Consent Withdrawal Evidence Document · Hrm discharge summary 20260618 · WSIB Form 8 (filed) · WSIB Form 8 Template (with field mapping)

Cardiology Consult Letter (received)

An anticoagulation review that arrived as a file from outside the practice -- a DocumentReference rather than a Composition for exactly that reason. The quoted passage is reproduced in description so the AI summary's citation resolves to text that can be checked. Author is deliberately absent, because the letter was written by a consultant this EMR does not hold

DocumentReference/cardio-consult-20250322 — claims conformance to DocumentReference Profile

{
  "resourceType": "DocumentReference",
  "id": "cardio-consult-20250322",
  "meta": {
    "profile": [
      "../StructureDefinition/nexus-emr-core-documentreference"
    ]
  },
  "text": {
    "status": "generated",
    "div": "<div xmlns="http://www.w3.org/1999/xhtml"><p>Cardiology consultation letter for Avery Linwood, received from the consulting cardiologist on 22 March 2025 and filed to the chart as a PDF. An anticoagulation review: continue warfarin at the current dose.</p><p>This is a <b>DocumentReference</b> rather than a Composition because it arrived as a file from outside the practice -- we hold the bytes, not the authored text. It is the source entity the AI-generated pre-visit summary cites for its warfarin statement, and the passage quoted in that citation is reproduced in <code>description</code> below.</p><p><code>author</code> is deliberately absent: the letter was written by a consultant outside this practice, and naming a practitioner the EMR does not hold would fabricate an author.</p></div>"
  },
  "status": "current",
  "type": {
    "coding": [
      {
        "system": "http://loinc.org",
        "code": "11488-4",
        "display": "Consult Note"
      }
    ],
    "text": "Consult Note"
  },
  "category": [
    {
      "text": "Cardiology"
    }
  ],
  "subject": {
    "reference": "Patient/avery-linwood",
    "display": "Avery Linwood"
  },
  "date": "2025-03-22T16:40:00-06:00",
  "description": "Anticoagulation review. Continue warfarin 5 mg daily at the current dose; INR has been therapeutic for three consecutive checks.",
  "custodian": {
    "reference": "Organization/cedarbrook-clinic"
  },
  "content": [
    {
      "attachment": {
        "contentType": "application/pdf",
        "language": "en-CA",
        "title": "Cardiology Consult Letter - March 22, 2025",
        "creation": "2025-03-22T16:40:00-06:00",
        "size": 243,
        "data": "JVBERi0xLjQKJeLjz9MKMSAwIG9iago8PAovVHlwZSAvQ2F0YWxvZwovUGFnZXMgMiAwIFIKPj4KZW5kb2JqCjIgMCBvYmoKPDwKL1R5cGUgL1BhZ2VzCi9LaWRzIFszIDAgUl0KL0NvdW50IDEKPD4KZW5kb2JqCjMgMCBvYmoKPDwKL1R5cGUgL1BhZ2UKL1BhcmVudCAyIDAgUgovTWVkaWFCb3ggWzAgMCA2MTIgNzkyXQovUmVzb3VyY2VzIDw8L0ZvbnQgPDwvRjEgNCAwIFI+Pj4+Ci9Db250ZW50cyA1IDAgUgo+PgplbmRvYmoK"
      }
    }
  ]
}

Referenced by: AI-Generated Summary With Per-Fact Citations