R4 Ballot #1 #2 (Mixed Normative/Trial use)

This page is part of the FHIR Specification (v3.3.0: (v3.5.0: R4 Ballot 2). #2). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.39.8 2.41.8 Resource DocumentReference - Mappings

Structured Documents Work Group Maturity Level : N/A Ballot Status : Informative Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Mappings:

FiveWs Pattern

Workflow Pattern

HL7 v2 Mapping

CDA (R2)

RIM Mapping

XDS metadata equivalent

FHIR Composition

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

2.39.8.1 2.41.8.1 Mappings for FiveWs Pattern (http://hl7.org/fhir/fivews) ( http://hl7.org/fhir/fivews )

DocumentReference
    masterIdentifier FiveWs.identifier
    identifier FiveWs.identifier
    status FiveWs.status
    docStatus FiveWs.status
    type FiveWs.class
    class     category FiveWs.class
    subject FiveWs.subject[x]
    created FiveWs.done[x]     date FiveWs.recorded
    agent FiveWs.author
    authenticator FiveWs.witness
        encounter FiveWs.context

2.39.8.2 2.41.8.2 Mappings for Workflow Pattern (http://hl7.org/fhir/workflow) ( http://hl7.org/fhir/workflow )

DocumentReference Event
    masterIdentifier Event.identifier
    identifier Event.identifier
    status Event.status
    type Event.code
    subject Event.subject
    created     date Event.occurrence[x]
    agent Event.performer
        type Event.performer.function
        who Event.performer.actor
    authenticator Event.performer.actor
    custodian Event.performer.actor
        encounter Event.context

2.39.8.3 2.41.8.3 Mappings for HL7 v2 Mapping (http://hl7.org/v2)

DocumentReference
    masterIdentifier TXA-12
    identifier TXA-16?
    status TXA-19
    docStatus TXA-17
    type TXA-2
    class     category
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
    created TXA-6     date
    agent
        type
        who TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    authenticator TXA-10
    custodian
    relatesTo
        code
        target
    description TXA-25
    securityLabel TXA-18
    content
        attachment TXA-3 for mime type
        format
    context
        encounter
        event
        period
        facilityType
        practiceSetting
        sourcePatientInfo
        related

2.41.8.4 Mappings for CDA (R2) (http://hl7.org/v3/cda)

            identifier DocumentReference when describing a CDA
    masterIdentifier ClinicalDocument/id
            ref     identifier
    status
    docStatus
    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 ClinicalDocument/effectiveTime
    agent ClinicalDocument/author
        type
        who
    authenticator ClinicalDocument/legalAuthenticator
    custodian
    relatesTo
        code
        target
    description
    securityLabel ClinicalDocument/confidentialityCode/@code
    content
        attachment ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/efectiveTime
        format derived from the IHE Profile or Implementation Guide templateID
    context
        encounter
        event
        period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
        facilityType usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
        practiceSetting usually from a mapping to a local ValueSet
        sourcePatientInfo ClinicalDocument/recordTarget/
        related ClinicalDocument/relatedDocument

2.39.8.4 2.41.8.5 Mappings for RIM Mapping (http://hl7.org/v3)

            identifier ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] .id             ref ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct].text.reference
DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    masterIdentifier .id
    identifier .id / .setId
    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
    class     category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    subject .participation[typeCode="SBJ"].role[typeCode="PAT"]
    created .effectiveTime[type="TS"]     date .availabilityTime[type="TS"]
    agent .participation
        type .participation.typeCode
        who .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    authenticator .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
    custodian .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
    relatesTo .outboundRelationship
        code .outboundRelationship.typeCode
        target .target[classCode="DOC", moodCode="EVN"].id
    description .outboundRelationship[typeCode="SUBJ"].target.text
    securityLabel .confidentialityCode
    content document.text
        attachment document.text
        format document.text
    context outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
        encounter unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
        event .code
        period .effectiveTime
        facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        sourcePatientInfo .participation[typeCode="SBJ"].role[typeCode="PAT"]
        related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]

2.39.8.5 2.41.8.6 Mappings for XDS metadata equivalent (http://ihe.net/xds) ( http://ihe.net/xds )

DocumentReference
    masterIdentifier DocumentEntry.uniqueId
    identifier DocumentEntry.entryUUID
    status DocumentEntry.availabilityStatus
    docStatus
    type DocumentEntry.type
    class     category DocumentEntry.class
    subject DocumentEntry.patientId
    created     date DocumentEntry.creationTime
    agent DocumentEntry.author
        type
        who
    authenticator DocumentEntry.legalAuthenticator
    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.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title
        format DocumentEntry.formatCode
    context
        encounter
        event DocumentEntry.eventCodeList
        period DocumentEntry.serviceStartTime DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
        facilityType DocumentEntry.healthcareFacilityTypeCode
        practiceSetting DocumentEntry.practiceSettingCode
        sourcePatientInfo DocumentEntry.sourcePatientInfo DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
        related DocumentEntry.referenceIdList

2.41.8.7 Mappings for FHIR Composition (http://hl7.org/fhir/composition)

DocumentReference when describing a Composition
            identifier     masterIdentifier Composition.identifier
    identifier
            ref     status
    docStatus Composition.status
    type Composition.type
    category Composition.class
    subject Composition.subject
    date Composition.date
    agent Composition.author
        type
        who
    authenticator Composition.attester
    custodian Composition.custodian
    relatesTo Composition.relatesTo
        code Composition.relatesTo.code
        target Composition.relatesTo.target
    description
    securityLabel Composition.confidentiality, Composition.meta.security
    content Bundle(Composition+*)
        attachment Composition.language,
Composition.title,
Composition.date
        format Composition.meta.profile
    context
        encounter Composition.encounter
        event Composition.event.code
        period Composition.event.period
        facilityType usually from a mapping to a local ValueSet
        practiceSetting usually from a mapping to a local ValueSet
        sourcePatientInfo Composition.subject
        related Composition.event.detail