Release 4B Snapshot 3: Connectathon 32 Base

This page is part of the FHIR Specification (v4.3.0: R4B - STU (v5.0.0-snapshot3: R5 Snapshot #3, to support Connectathon 32 ). 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

2.42.9 10.2.9 Resource DocumentReference - Mappings

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

Mappings:

FiveWs Pattern Mapping

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).

2.42.9.1 10.2.9.1 FiveWs Pattern Mapping ( http://hl7.org/fhir/fivews icon )

DocumentReference
    masterIdentifier FiveWs.identifier     identifier FiveWs.identifier
    status FiveWs.status
    docStatus FiveWs.status
    type FiveWs.class FiveWs.what[x]
    category FiveWs.class FiveWs.what[x]
    subject FiveWs.subject[x]
    date     context FiveWs.recorded FiveWs.context
    authenticator     date FiveWs.witness FiveWs.recorded
        encounter         party FiveWs.context FiveWs.witness

2.42.9.2 10.2.9.2 Workflow Pattern ( http://hl7.org/fhir/workflow icon )

DocumentReference Event
    masterIdentifier Event.identifier     identifier Event.identifier
    status Event.status
    type Event.code
    subject Event.subject
    date     context Event.occurrence[x] Event.context
    author     date Event.performer.actor Event.occurrence[x]
    authenticator     author Event.performer.actor
    custodian     attester Event.performer.actor
        encounter     custodian Event.context Event.performer.actor

2.42.9.3 10.2.9.3 HL7 v2 Mapping ( http://hl7.org/v2 icon )

DocumentReference
    masterIdentifier     identifier TXA-12
    identifier     basedOn TXA-16?
    status TXA-19
    docStatus TXA-17
    type TXA-2
    category
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
    date     context
    author     event TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    authenticator     facilityType TXA-10
    custodian     practiceSetting
    relatesTo     period
        code     date
        target     author TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    description     attester TXA-25
    securityLabel         mode TXA-18
    content         time
        attachment         party TXA-3 for mime type TXA-10
        format     custodian
    context     relatesTo
        encounter         code
        event         target
        period     description TXA-25
    securityLabel TXA-18
        facilityType     content
        practiceSetting         attachment TXA-3 for mime type
        sourcePatientInfo         profile
        related             value[x]

2.42.9.4 10.2.9.4 CDA (R2) ( http://hl7.org/v3/cda icon )

DocumentReference when describing a CDA
    masterIdentifier     identifier ClinicalDocument/id
    identifier     basedOn
    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     context
    author     event ClinicalDocument/author
    authenticator     facilityType ClinicalDocument/legalAuthenticator usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
    custodian     practiceSetting usually from a mapping to a local ValueSet
    relatesTo     period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
        code     date
        target     author ClinicalDocument/author
    description     attester .authenticator/.legalAuthenticator
    securityLabel         mode ClinicalDocument/confidentialityCode/@code implied by .authenticator/.legalAuthenticator
    content         time .authenticator.time
        party .authenticator.assignedEnttty
        attachment     custodian ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        format     relatesTo derived from the IHE Profile or Implementation Guide templateID
    context         code ClinicalDocument/relatedDocument/typeCode
        encounter         target ClinicalDocument/relatedDocument/parentDocument
        event     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

2.42.9.5 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 document.text document.text outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] .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     facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    custodian     practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    relatesTo     period .effectiveTime
        code     date .availabilityTime[type="TS"]
        target     author .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    description     attester .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
    securityLabel         mode unique(./modeCode)
    content         time ./time[type="TS" and isNormalDatatype()]
        attachment         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()]
        format     custodian .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
    context     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

2.42.9.6 10.2.9.6 XDS metadata equivalent ( http://ihe.net/xds https://profiles.ihe.net/ITI/HIE-Whitepaper icon )

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

2.42.9.7 10.2.9.7 FHIR Composition ( http://hl7.org/fhir/composition icon )

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