Release 4B 5

This page is part of the FHIR Specification (v4.3.0: R4B (v5.0.0: R5 - STU ). The This is the current published version which supercedes in it's permanent home (it will always be available at this version is 5.0.0 . URL). For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B 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 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 infrastructure.documents
    masterIdentifier     identifier FiveWs.identifier
    identifier     version FiveWs.identifier FiveWs.version
    status FiveWs.status
    docStatus FiveWs.status
    type     modality FiveWs.class
    type 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.encounter
    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 V2 Mapping ( http://hl7.org/v2 icon )

DocumentReference
    masterIdentifier     identifier TXA-12
    identifier     version TXA-16?
    basedOn
    status TXA-19
    docStatus TXA-17
    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     bodySite TXA-10
    custodian     facilityType
    relatesTo     practiceSetting
        code     period
        target     date
    description     author TXA-25 TXA-9 (No standard way to indicate a Device in HL7 V2 MDM message)
    securityLabel     attester TXA-18
    content         mode
        attachment         time TXA-3 for mime type
        format         party TXA-10
    context     custodian
        encounter     relatesTo
        event         code
        period         target
        facilityType     description TXA-25
    securityLabel TXA-18
        practiceSetting     content
        sourcePatientInfo         attachment TXA-3 for mime type
        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     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     bodySite ClinicalDocument/legalAuthenticator
    custodian     facilityType usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
    relatesTo     practiceSetting usually from a mapping to a local ValueSet
        code     period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
        target     date
    description     author ClinicalDocument/author
    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 .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     bodySite .targetSiteCode
    custodian     facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    relatesTo     practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        code     period .effectiveTime
        target     date .availabilityTime[type="TS"]
    description     author .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    securityLabel     attester .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
    content         mode document.text unique(./modeCode)
        attachment         time ./time[type="TS" and isNormalDatatype()]
        format         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

2.42.9.6 10.2.9.6 XDS metadata equivalent ( http://ihe.net/xds 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.referenceIdList
    authenticator     bodySite DocumentEntry.legalAuthenticator
    custodian     facilityType DocumentEntry.healthcareFacilityTypeCode
    relatesTo     practiceSetting DocumentEntry Associations DocumentEntry.practiceSettingCode
        code     period DocumentEntry Associations type DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
        target     date DocumentEntry Associations reference
    description     author DocumentEntry.comments DocumentEntry.author
    securityLabel     attester DocumentEntry.confidentialityCode DocumentEntry.legalAuthenticator
    content         mode
        attachment         time DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        format         party DocumentEntry.formatCode
    context     custodian
        encounter     relatesTo DocumentEntry Associations
        code DocumentEntry Associations type
        event         target DocumentEntry.eventCodeList DocumentEntry Associations reference
        period     description DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime DocumentEntry.comments
        facilityType     securityLabel DocumentEntry.healthcareFacilityTypeCode DocumentEntry.confidentialityCode
        practiceSetting     content DocumentEntry.practiceSettingCode
        sourcePatientInfo         attachment DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        related         profile DocumentEntry.referenceIdList DocumentEntry.formatCode
            value[x] 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     version Composition.version
    basedOn
    status
    docStatus Composition.status
    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     bodySite Composition.attester
    custodian     facilityType Composition.custodian usually from a mapping to a local ValueSet
    relatesTo     practiceSetting Composition.relatesTo usually from a mapping to a local ValueSet
        code     period Composition.relatesTo.code Composition.event.period
        target     date Composition.relatesTo.target Composition.date
    description     author Composition.author
    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.type
        encounter         target Composition.encounter Composition.relatesTo.resourceReference
        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