DocumentReference - FHIR v4.0.1

Release 4

This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). 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

2.42.8 Resource DocumentReference - Mappings

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

Mappings:

FiveWs Pattern Mapping

XDS metadata equivalent

FHIR Composition

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

2.42.8.1 FiveWs Pattern Mapping (http://hl7.org/fhir/fivews )

DocumentReference

masterIdentifier FiveWs.identifier

identifier FiveWs.identifier

status FiveWs.status

docStatus FiveWs.status

type FiveWs.class

category FiveWs.class

subject FiveWs.subject[x]

date FiveWs.recorded

authenticator FiveWs.witness

encounter FiveWs.context

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

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 )

DocumentReference

masterIdentifier TXA-12

identifier TXA-16?

status TXA-19

docStatus TXA-17

type TXA-2

2.42.8.4 CDA (R2) (http://hl7.org/v3/cda )

DocumentReference when describing a CDA

masterIdentifier ClinicalDocument/id

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

author ClinicalDocument/author

authenticator ClinicalDocument/legalAuthenticator

custodian

relatesTo

code

target

description

securityLabel ClinicalDocument/confidentialityCode/@code

content

attachment 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 )

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

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]

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

DocumentReference

masterIdentifier DocumentEntry.uniqueId

identifier DocumentEntry.entryUUID

status DocumentEntry.availabilityStatus

docStatus

type DocumentEntry.type

category DocumentEntry.class

subject DocumentEntry.patientId

date

author DocumentEntry.author

authenticator DocumentEntry.legalAuthenticator

custodian

relatesTo DocumentEntry Associations

code DocumentEntry Associations type

target DocumentEntry Associations reference

description DocumentEntry.comments

securityLabel DocumentEntry.confidentialityCode

content

attachment 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.serviceStopTime

facilityType DocumentEntry.healthcareFacilityTypeCode

practiceSetting DocumentEntry.practiceSettingCode

sourcePatientInfo DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId

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

DocumentReference when describing a Composition

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