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Guidance for populating and consuming the DocumentReference resource


The headings below list the elements of the DocumentReference resource and describe how to populate and consume them.

DocumentReference elements


Data type: Id Optionality: Mandatory Cardinality: 1..1

The logical identifier of the DocumentReference resource.


Data type: uri Optionality: Mandatory Cardinality: 1..*

The DocumentReference profile URL.

Fixed value


Data type: Id Optionality: Required Cardinality: 0..1

Master Version Specific Identifier. This unique identifier is used to identify the version of the document


Data type: Identifier Optionality: Mandatory Cardinality: 1..*

This MUST be populated with a globally unique and persistent identifier (that is, it doesn’t change between requests and therefore stored with the source data). This MUST be scoped by a provider specific namespace for the identifier.

Where consuming systems are integrating data from this resource to their local system, they MUST also persist this identifier at the same time.


Data type: code Optionality: Mandatory Cardinality: 1..1

current | superseded | entered-in-error This field will always have default value of current as only the latest version of the document is retrieved.


Data type: codeableConcept Optionality: Mandatory Cardinality: 1..1

Kind of document, a value SHOULD be taken from the SNOMED refset 1127551000000109 |Record composition type simple reference set (foundation metadata concept)|. Other classifications of documents SHOULD be sent as text.


Data type: Reference(CareConnect-GPC-Patient-1 | CareConnect-GPC-Practitioner-1) Optionality: Mandatory Cardinality: 1..1

A reference to the patient who is the subject of the document.


Data type: DateTime Optionality: Required Cardinality: 0..1

Creation/Edit datetime of the document.


Data type: Instant Optionality: Mandatory Cardinality: 1..1

When the GP Practice added the document to their clinical system.


Data type: Reference ( CareConnect-GPC-Practitioner-1 | CareConnect-GPC-Organization-1 ) Optionality: Required Cardinality: 0..1

Who and/or what authored the document.


Data type: Reference(Organisation) Optionality: Required Cardinality: 0..1

Organisation which maintains this document.


Data type: string Optionality: Required Cardinality: 0..1

Human-readable description (title).


Data type: url Optionality: Required Cardinality: 0..1

URL to retrieve the document, this MUST be populated when the document is available. This MUST contain the full URL to the Binary resource, including when the DocumentReference is being included in an Access Record Structured Bundle.


Data type: unsignedInt Optionality: Mandatory Cardinality: 1..1

Size of the file.


Data type: string Optionality: Optional Cardinality: 0..1

To be used when only a placeholder for a document is available. This SHOULD be populated with the reason why the file isn’t available.


Data type: Code Optionality: Mandatory Cardinality: 1..1

MIME type for the document.


Data type: Reference(CareConnect-GPC-Encounter-1) Optionality: Required/Optional Cardinality: 0..1

Reference to the consultation the document was created/attached in.


Data type: codeableConcept Optionality: Required Cardinality: 0..1

Additional details about where the content was created (for example, clinical specialty), the value SHOULD be taken from the refset. Other classifications of documents should be sent as text.


Data type: BackboneElement Optionality: Optional Cardinality: 0..*

Reference to other resource(s) to which the document is linked to, for instance this could be a reference to an inbound referral.

Elements not in use

The following elements MUST NOT be populated:


Data type: Reference(preliminary | final | appended | amended | entered-in-error)

This is not required by GP Connect.


Data type: codeableConcept

Categorization of document is not required by GP Connect.


Data type: Reference ( CareConnect-GPC-Practitioner-1 | CareConnect-GPC-Organization-1 )

Who/what authenticated the document is not required by GP Connect.

Data type: base64Binary

Data of the attachment is not required by GP Connect as it will be populated in FHIR binary resource.


Data type: code

replaces | transforms | signs | appends Relationships to other documents is not required by GP Connect.

Data type:Reference(CareConnect-GPC-Patient-1) Optionality: Required Cardinality: 0..1

Patient demographics from source.


Data type: codeableConcept

Document security-tags is not required by GP Connect.

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