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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 Ballot Standards Status : Informative Security Category : Not Classified Compartments : Device , Encounter , Group , Patient , Practitioner , RelatedPerson

Mappings:

RIM FiveWs Pattern Mapping

Workflow Pattern

HL7 v2 V2 Mapping

CDA (R2)

RIM Mapping

XDS metadata equivalent

FHIR Composition

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

2.42.8.1 10.2.9.1 Mappings for RIM FiveWs Pattern Mapping (http://hl7.org/v3) ( http://hl7.org/fhir/fivews icon )

.id .id / .setId .statusCode ./code .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
DocumentReference infrastructure.documents
Document[classCode="DOC" and moodCode="EVN"]     identifier FiveWs.identifier
    masterIdentifier     version FiveWs.version
    status FiveWs.status
    identifier     docStatus FiveWs.status
    modality FiveWs.class
    status     type FiveWs.what[x]
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and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"     category FiveWs.what[x]
    docStatus     subject FiveWs.subject
    context FiveWs.context
    type     period FiveWs.done[x]
    date FiveWs.recorded
    class     author FiveWs.author
        party FiveWs.witness

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

.participation[typeCode="SBJ"].role[typeCode="PAT"] .effectiveTime[type="TS"] .availabilityTime[type="TS"] .participation[typeCode="AUT"].role[classCode="ASSIGNED"] .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG"
    subject DocumentReference Event
    identifier Event.identifier
    created     basedOn Event.basedOn
    status Event.status
    indexed     type Event.code
    category Event.category
    author     subject Event.subject
    context Event.encounter
    authenticator     period Event.occurrence[x]
    date Event.recorded
    custodian     author Event.performer.actor
    attester Event.performer
        mode Event.performer.function
        party Event.performer.actor

10.2.9.3 HL7 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 determinerCode="INST"] 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.
.outboundRelationship .target[classCode="DOC", moodCode="EVN"].id .confidentialityCode .participation[typeCode="LOC"].role[classCode="DSDLOC"].code ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct].text.reference
DocumentReference
    relatesTo     identifier TXA-12
    version
        code     basedOn .outboundRelationship.typeCode
        target     status TXA-19
    docStatus TXA-17
    description     modality .outboundRelationship[typeCode="SUBJ"].target.text
    securityLabel     type TXA-2
    category
    content     subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 V2 MDM message)
document.text     context
        attachment     event
document.text     related
        format     bodyStructure
document.text     facilityType
    context     practiceSetting
outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']     period
        encounter     date
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])     author TXA-9 (No standard way to indicate a Device in HL7 V2 MDM message)
        event     attester .code
        period         mode .effectiveTime
        facilityType         time .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        practiceSetting         party TXA-10
    custodian
        sourcePatientInfo     relatesTo .participation[typeCode="SBJ"].role[typeCode="PAT"]
        related         code ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
            identifier         target ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] .id
            ref     description TXA-25
    securityLabel TXA-18
    content
        attachment TXA-3 for mime type
        profile
            value[x]

2.42.8.2 10.2.9.4 Mappings for HL7 v2 Mapping (http://hl7.org/v2) CDA (R2) ( http://hl7.org/v3/cda icon )

DocumentReference when describing a CDA
    masterIdentifier     identifier TXA-12 ClinicalDocument/id
    identifier     version
TXA-16?     basedOn
    status TXA-19
    docStatus
TXA-17     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.
TXA-2     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
    class     subject ClinicalDocument/recordTarget/
    context
    subject     event
PID-3 (No standard way     related
    bodyStructure
    facilityType usually a mapping to define a Practitioner or Group subject in HL7 v2 MDM message) local ValueSet. Must be consistent with /clinicalDocument/code
    created     practiceSetting usually from a mapping to a local ValueSet
TXA-6     period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
    indexed     date
    author ClinicalDocument/author
TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)     attester .authenticator/.legalAuthenticator
    authenticator         mode implied by .authenticator/.legalAuthenticator
TXA-10         time .authenticator.time
        party .authenticator.assignedEnttty
    custodian
    relatesTo
        code ClinicalDocument/relatedDocument/typeCode
        target ClinicalDocument/relatedDocument/parentDocument
    description TXA-25
    securityLabel TXA-18 ClinicalDocument/confidentialityCode/@code
    content
        attachment ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
TXA-3 for mime type         profile derived from the IHE Profile or Implementation Guide templateID
        format             value[x] derived from the IHE Profile or Implementation Guide templateID

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

DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    identifier .id / .setId
    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"]
    context unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
    event .code
        encounter     related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
    bodyStructure .targetSiteCode
        event     facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        period     period .effectiveTime
    date .availabilityTime[type="TS"]
        facilityType     author .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    attester .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
        practiceSetting         mode unique(./modeCode)
        time ./time[type="TS" and isNormalDatatype()]
        sourcePatientInfo         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()]
    custodian .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
        related     relatesTo .outboundRelationship
        code .outboundRelationship.typeCode
            identifier         target .target[classCode="DOC", moodCode="EVN"].id
    description .outboundRelationship[typeCode="SUBJ"].target.text
            ref     securityLabel .confidentialityCode
    content document.text
        attachment document.text
        profile document.text
            value[x] document.text

2.42.8.3 10.2.9.6 Mappings for 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 status DocumentEntry.availabilityStatus
    docStatus
    modality
    type DocumentEntry.typeCode
DocumentEntry.type     category DocumentEntry.classCode
    class     subject DocumentEntry.patientId
DocumentEntry.class     context
    subject     event DocumentEntry.eventCodeList
DocumentEntry.patientId     related DocumentEntry.referenceIdList
    created     bodyStructure
DocumentEntry.submissionTime     facilityType DocumentEntry.healthcareFacilityTypeCode
    indexed     practiceSetting DocumentEntry.practiceSettingCode
DocumentEntry.submissionTime     period DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
    author     date
    author DocumentEntry.author
    authenticator     attester DocumentEntry.legalAuthenticator
        mode
        time
        party
    custodian
    relatesTo DocumentEntry Associations
        code DocumentEntry Associations type
        target DocumentEntry Associations reference
    description DocumentEntry.description DocumentEntry.comments
    securityLabel DocumentEntry.confidentialityCode
    content
        attachment DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.repositoryUniqueId, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        format         profile DocumentEntry.formatCode
            value[x] DocumentEntry.formatCode

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

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