FHIR Release 3 (STU) 4

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2.42.8 Resource DocumentReference - Mappings

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

Mappings:

RIM FiveWs Pattern Mapping

Workflow Pattern

HL7 v2 Mapping

CDA (R2)

RIM Mapping

XDS metadata equivalent

FHIR Composition

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

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

.id .id / .setId .statusCode ./code .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code .participation[typeCode="SBJ"].role[typeCode="PAT"] .effectiveTime[type="TS"] .availabilityTime[type="TS"]
DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    masterIdentifier FiveWs.identifier
    identifier FiveWs.identifier
    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and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" FiveWs.status
    docStatus FiveWs.status
    type FiveWs.class
    class     category FiveWs.class
    subject FiveWs.subject[x]
    created     date FiveWs.recorded
    indexed     authenticator FiveWs.witness
        encounter FiveWs.context

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

.participation[typeCode="AUT"].role[classCode="ASSIGNED"] .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
DocumentReference Event
    masterIdentifier Event.identifier
    identifier Event.identifier
    status Event.status
    type Event.code
    subject Event.subject
    date Event.occurrence[x]
    author Event.performer.actor
    authenticator Event.performer.actor
    custodian Event.performer.actor
        encounter Event.context

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

.outboundRelationship .outboundRelationship.typeCode .target[classCode="DOC", moodCode="EVN"].id .outboundRelationship[typeCode="SUBJ"].target.text .confidentialityCode .code .effectiveTime .participation[typeCode="LOC"].role[classCode="DSDLOC"].code .participation[typeCode="LOC"].role[classCode="DSDLOC"].code .participation[typeCode="SBJ"].role[typeCode="PAT"]
DocumentReference
    masterIdentifier TXA-12
    identifier 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
    author 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 document.text
        attachment document.text TXA-3 for mime type
        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
        period
        facilityType
        practiceSetting
        sourcePatientInfo         related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
            identifier ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] .id         related             ref ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct].text.reference

2.42.8.2 2.42.8.4 Mappings for HL7 v2 Mapping (http://hl7.org/v2) CDA (R2) ( http://hl7.org/v3/cda )

DocumentReference when describing a CDA
    masterIdentifier TXA-12 ClinicalDocument/id
    identifier TXA-16?
    status TXA-19
    docStatus TXA-17
    type TXA-2 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.
    class     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 PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message) ClinicalDocument/recordTarget/
    created     date TXA-6     indexed
    author TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message) ClinicalDocument/author
    authenticator TXA-10 ClinicalDocument/legalAuthenticator
    custodian
    relatesTo
        code
        target
    description TXA-25
    securityLabel TXA-18 ClinicalDocument/confidentialityCode/@code
    content
        attachment TXA-3 for mime type ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        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

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

            identifier DocumentReference Document[classCode="DOC" and moodCode="EVN"]
            ref     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
    category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    subject .participation[typeCode="SBJ"].role[typeCode="PAT"]
    date .availabilityTime[type="TS"]
    author .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]

2.42.8.3 2.42.8.6 Mappings for XDS metadata equivalent (http://ihe.net/xds) ( http://ihe.net/xds )

DocumentReference
    masterIdentifier DocumentEntry.uniqueId
    identifier DocumentEntry.entryUUID
    status DocumentEntry status DocumentEntry.availabilityStatus
    docStatus
    type DocumentEntry.type
    class     category DocumentEntry.class
    subject DocumentEntry.patientId
    created     date DocumentEntry.submissionTime     indexed DocumentEntry.submissionTime
    author DocumentEntry.author
    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.title DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        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

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

            identifier DocumentReference when describing a Composition
            ref     masterIdentifier Composition.identifier
    identifier
    status
    docStatus Composition.status
    type Composition.type
    category Composition.class
    subject Composition.subject
    date Composition.date
    author Composition.author
    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