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2.42.8 10.2.9 Resource DocumentReference - Mappings

Maturity Level : N/A
Structured Documents Responsible Owner: Orders and Observations icon Work Group Standards Status : Informative Security Category : Not Classified Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

Mappings:

FiveWs Pattern Mapping

Workflow Pattern

HL7 v2 V2 Mapping

CDA (R2)

RIM Mapping

XDS metadata equivalent

FHIR Composition

Mappings for the documentreference DocumentReference resource (see Mappings to Other Standards for further information & status).

2.42.8.1 10.2.9.1 FiveWs Pattern Mapping ( http://hl7.org/fhir/fivews icon )

DocumentReference infrastructure.documents
    masterIdentifier     identifier FiveWs.identifier
    identifier     version FiveWs.identifier FiveWs.version
    status FiveWs.status
    docStatus FiveWs.status
    type     modality FiveWs.class
    category     type FiveWs.what[x]
FiveWs.class     category FiveWs.what[x]
    subject FiveWs.subject
FiveWs.subject[x]     context FiveWs.context
    date     period FiveWs.done[x]
    date FiveWs.recorded
    authenticator     author FiveWs.witness FiveWs.author
        encounter         party FiveWs.context FiveWs.witness

2.42.8.2 10.2.9.2 Workflow Pattern ( http://hl7.org/fhir/workflow icon )

DocumentReference Event
    masterIdentifier     identifier Event.identifier
    identifier     basedOn Event.identifier Event.basedOn
    status Event.status
    type Event.code
    subject     category Event.category
    subject Event.subject
    date     context Event.encounter
    period Event.occurrence[x]
    author     date Event.performer.actor Event.recorded
    authenticator     author Event.performer.actor
    custodian     attester Event.performer.actor Event.performer
        encounter         mode Event.performer.function
Event.context         party Event.performer.actor

2.42.8.3 10.2.9.3 HL7 v2 V2 Mapping ( http://hl7.org/v2 icon )

The mappings provided in this tab are indicative of how HL7 v2 fields relate to HL7 FHIR attributes in this resource, but is not complete and without critical HL7 v2 context. The HL7 v2-FHIR Implementation guide, located here icon , provides additional guidance on transforming an HL7 v2 message to FHIR resources for FHIR R4 and FHIR R6.
DocumentReference
    masterIdentifier     identifier TXA-12
    identifier     version
TXA-16?     basedOn
    status TXA-19
    docStatus TXA-17
    type     modality
    type TXA-2
    category
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 V2 MDM message)
    date     context
    author     event TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    authenticator     related TXA-10
    custodian     bodyStructure
    relatesTo     facilityType
        code     practiceSetting
        target     period
    description     date TXA-25
    securityLabel     author TXA-18 TXA-9 (No standard way to indicate a Device in HL7 V2 MDM message)
    content     attester
        attachment         mode TXA-3 for mime type
        format         time
    context         party TXA-10
    custodian
        encounter     relatesTo
        event         code
        period         target
        facilityType     description TXA-25
        practiceSetting     securityLabel TXA-18
    content
        sourcePatientInfo         attachment TXA-3 for mime type
        profile
        related             value[x]

2.42.8.4 10.2.9.4 CDA (R2) ( http://hl7.org/v3/cda icon )

DocumentReference when describing a CDA
    masterIdentifier     identifier ClinicalDocument/id
    identifier     version
    basedOn
    status
    docStatus
    modality
    type ClinicalDocument/code/@code

The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.
    category Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code
    subject ClinicalDocument/recordTarget/
    date     context
    author     event ClinicalDocument/author
    authenticator     related ClinicalDocument/legalAuthenticator
    custodian     bodyStructure
    relatesTo     facilityType usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
        code     practiceSetting usually from a mapping to a local ValueSet
        target     period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
    description     date
    securityLabel     author ClinicalDocument/confidentialityCode/@code ClinicalDocument/author
    content     attester .authenticator/.legalAuthenticator
        mode implied by .authenticator/.legalAuthenticator
        attachment         time .authenticator.time
ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date         party .authenticator.assignedEnttty
        format     custodian derived from the IHE Profile or Implementation Guide templateID
    context     relatesTo
        encounter         code ClinicalDocument/relatedDocument/typeCode
        event         target ClinicalDocument/relatedDocument/parentDocument
    description
        period     securityLabel ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value ClinicalDocument/confidentialityCode/@code
        facilityType     content usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
        practiceSetting         attachment usually from a mapping to a local ValueSet ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        sourcePatientInfo         profile ClinicalDocument/recordTarget/ derived from the IHE Profile or Implementation Guide templateID
        related             value[x] ClinicalDocument/relatedDocument derived from the IHE Profile or Implementation Guide templateID

2.42.8.5 10.2.9.5 RIM Mapping ( http://hl7.org/v3 icon )

.id / .setId .availabilityTime[type="TS"] .participation[typeCode="AUT"].role[classCode="ASSIGNED"] .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] .outboundRelationship .outboundRelationship.typeCode .target[classCode="DOC", moodCode="EVN"].id .outboundRelationship[typeCode="SUBJ"].target.text .confidentialityCode document.text .code .effectiveTime .participation[typeCode="LOC"].role[classCode="DSDLOC"].code .participation[typeCode="LOC"].role[classCode="DSDLOC"].code .participation[typeCode="SBJ"].role[typeCode="PAT"] ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    masterIdentifier     identifier .id / .setId
    identifier     basedOn .outboundRelationship[typeCode=FLFS].target
    status interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
    docStatus .statusCode
    type ./code
    category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    subject .participation[typeCode="SBJ"].role[typeCode="PAT"]
    date     context unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
    author     event .code
    authenticator     related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
    custodian     bodyStructure .targetSiteCode
    relatesTo     facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        code     practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        target     period .effectiveTime
    description     date .availabilityTime[type="TS"]
    securityLabel     author .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    content     attester .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
        attachment         mode document.text unique(./modeCode)
        format         time ./time[type="TS" and isNormalDatatype()]
document.text         party ./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
    context     custodian .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']     relatesTo .outboundRelationship
        encounter         code .outboundRelationship.typeCode
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])         target .target[classCode="DOC", moodCode="EVN"].id
        event     description .outboundRelationship[typeCode="SUBJ"].target.text
        period     securityLabel .confidentialityCode
        facilityType     content document.text
        practiceSetting         attachment document.text
        sourcePatientInfo         profile document.text
        related             value[x] document.text

2.42.8.6 10.2.9.6 XDS metadata equivalent ( http://ihe.net/xds https://profiles.ihe.net/ITI/TF/Volume3 icon )

DocumentReference DocumentEntry
    masterIdentifier     identifier DocumentEntry.entryUUID, DocumentEntry.uniqueId
    identifier     version
DocumentEntry.entryUUID     basedOn DocumentEntry.referenceIdList
    status DocumentEntry.availabilityStatus
    docStatus
    modality
    type DocumentEntry.type DocumentEntry.typeCode
    category DocumentEntry.class DocumentEntry.classCode
    subject DocumentEntry.patientId
    date     context
    author     event DocumentEntry.author DocumentEntry.eventCodeList
    authenticator     related DocumentEntry.legalAuthenticator DocumentEntry.referenceIdList
    custodian     bodyStructure
    relatesTo     facilityType DocumentEntry Associations DocumentEntry.healthcareFacilityTypeCode
        code     practiceSetting DocumentEntry Associations type DocumentEntry.practiceSettingCode
        target     period DocumentEntry Associations reference DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
    description     date DocumentEntry.comments
    securityLabel     author DocumentEntry.confidentialityCode DocumentEntry.author
    content     attester DocumentEntry.legalAuthenticator
        attachment         mode DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        format         time DocumentEntry.formatCode
    context         party
        encounter     custodian
        event     relatesTo DocumentEntry.eventCodeList DocumentEntry Associations
        period         code DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime DocumentEntry Associations type
        facilityType         target DocumentEntry.healthcareFacilityTypeCode DocumentEntry Associations reference
        practiceSetting     description DocumentEntry.comments
DocumentEntry.practiceSettingCode     securityLabel DocumentEntry.confidentialityCode
        sourcePatientInfo     content
DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId         attachment DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.repositoryUniqueId, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        related         profile DocumentEntry.formatCode
DocumentEntry.referenceIdList             value[x] DocumentEntry.formatCode

2.42.8.7 10.2.9.7 FHIR Composition ( http://hl7.org/fhir/composition icon )

DocumentReference when describing a Composition
    masterIdentifier     identifier Composition.identifier
    identifier     version Composition.version
    basedOn
    status
    docStatus Composition.status
    type     modality
    type Composition.type
    category Composition.class Composition.category
    subject Composition.subject
    date     context Composition.date Composition.encounter
    author     event Composition.author Composition.event.detail
    authenticator     related Composition.attester Composition.event.detail
    custodian     bodyStructure Composition.custodian
    relatesTo     facilityType Composition.relatesTo usually from a mapping to a local ValueSet
        code     practiceSetting Composition.relatesTo.code usually from a mapping to a local ValueSet
        target     period Composition.relatesTo.target Composition.event.period
    description     date Composition.date
    securityLabel     author Composition.confidentiality, Composition.meta.security Composition.author
    content     attester Bundle(Composition+*) Composition.attester
        attachment         mode Composition.language, Composition.title, Composition.date Composition.attester.mode
        format         time Composition.meta.profile Composition.attester.time
    context         party Composition.attester.party
        encounter     custodian Composition.encounter Composition.custodian
        event     relatesTo Composition.event.code Composition.relatesTo
        period         code Composition.event.period Composition.relatesTo.type
        facilityType         target usually from a mapping to a local ValueSet Composition.relatesTo.targetReference
        practiceSetting     description
usually from a mapping to a local ValueSet     securityLabel Bundle.meta.security
        sourcePatientInfo     content Bundle(Composition+*)
Composition.subject         attachment Composition.language,
Composition.title,
Composition.date
        related         profile Composition.meta.profile
Composition.event.detail             value[x] Composition.meta.profile