2nd DSTU Draft For Comment
This page is part of the FHIR Specification (v0.4.0: DSTU 2 Draft). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
Profile for XDSDocumentEntry
{
"resourceType": "Profile",
"id": "xds-documentreference",
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"url": "http://hl7.org/fhir/Profile/xds-documentreference",
"name": "XDS profile for Document Reference",
"publisher": "HL7",
"contact": [
{
"telecom": [
{
"system": "url",
"value": "http://www.hl7.org"
}
]
}
],
"description": "XDSDocumentEntry",
"status": "draft",
"date": "2012-06-24",
"type": "DocumentReference",
"base": "http://hl7.org/fhir/Profile/DocumentReference",
"snapshot": {
"element": [
{
"path": "DocumentReference",
"name": "DocumentReference",
"short": "XDSDocumentEntry",
"definition": "A reference to a document.",
"comments": "Usually, this is used for documents other than those defined by FHIR.",
"min": 1,
"max": "1",
"mapping": [
{
"identity": "rim",
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]"
}
]
},
{
"path": "DocumentReference.id",
"short": "Logical id of this artefact",
"definition": "The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes.",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
]
},
{
"path": "DocumentReference.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"type": [
{
"code": "Meta"
}
]
},
{
"path": "DocumentReference.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
],
"isModifier": true
},
{
"path": "DocumentReference.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource\n\nNot all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"name": "Language",
"isExtensible": false,
"conformance": "required",
"description": "A human language",
"referenceUri": "http://tools.ietf.org/html/bcp47"
}
},
{
"path": "DocumentReference.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"synonym": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"path": "DocumentReference.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"synonym": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.masterIdentifier",
"short": "XDSDocumentEntry.uniqueId",
"definition": "Globally unique identifier assigned to the document by the creating entity.\nA DocumentEntry representing a single document is identified by the uniqueId attribute; the linkage between DocumentEntry and the Document it represents is made with the uniqueId attribute.\nThis unique identifier may be used in other documents to reference this document.",
"comments": "CDA Document Id extension and root.",
"requirements": "The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g., for a DICOM standard document a 64 character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form oid^extension, where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.uniqueId"
},
{
"identity": "v2",
"map": "TXA-12-Unique Document Number"
},
{
"identity": "rim",
"map": ".id"
}
]
},
{
"path": "DocumentReference.identifier",
"short": "XDSDocumentEntry.referenceIdList",
"definition": "Other identifiers for the document.",
"comments": "Other identifiers can also include Identifiers may be Accession Numbers, Order Numbers, Referral Request \nIdentifiers, XDS Workflow Instance Identifiers.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.entryUUID"
},
{
"identity": "v2",
"map": "TXA-16-Unique Document File Name?"
},
{
"identity": "rim",
"map": ".id / .setId"
}
]
},
{
"path": "DocumentReference.subject",
"short": "XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo",
"definition": "The patientId represents the subject of care of the document. The value of the patientId shall be the same for all new documents of a SubmissionSet. Patient information typically includes: the patient first and last name, sex, and birth date.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Patient"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.patientId\nDocumentEntry.sourcePatientId\nDocumentEntry.SourcePatientInfo"
},
{
"identity": "v2",
"map": "PID-3-Patient ID List (No standard way to define a Practitioner or Group subject in V2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
}
]
},
{
"path": "DocumentReference.type",
"short": "XDSDocumentEntry.typeCode",
"definition": "The code specifying the particular kind of document (e.g., Prescription, Discharge Summary, Report). It is suggested that the XDS Affinity Domain draws these values from a coding scheme providing a coarse level of granularity (about 10 to 100 entries). Shall have a single value.",
"comments": "Key metadata element describing the document, used in searching/filtering.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"name": "DocumentType",
"isExtensible": true,
"conformance": "preferred",
"description": "Type of a composition",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/doc-codes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.type"
},
{
"identity": "v2",
"map": "TXA-2-Document Type"
},
{
"identity": "rim",
"map": "./code"
}
]
},
{
"path": "DocumentReference.class",
"short": "XDSDocumentEntry.classCode",
"definition": "A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type.",
"comments": "Helps humans to assess whether the document is of interest when viewing an list of documents.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"name": "DocumentClass",
"isExtensible": true,
"conformance": "example",
"description": "SubType of a clinical document",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/xds-typecodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.class"
},
{
"identity": "v2",
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code"
}
]
},
{
"path": "DocumentReference.format",
"short": "XDSDocumentEntry.formatCode",
"definition": "Code globally uniquely specifying the format of the document. Along with the typeCode, it should provide sufficient information to allow any potential XDS Document Consumer to know if it will be able to process the document. The formatCode shall be sufficiently specific to ensure processing/display by identifying a document encoding, structure and template (e.g., for a CDA Document, the fact that it complies with a CDA schema, possibly a template and the choice of a content-specific style sheet).",
"comments": "Helps the processing. Usually is a URN that identifies. For IHE defined Document Content profiles this is a urn issued by IHE.",
"min": 1,
"max": "1",
"type": [
{
"code": "uri"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.formatCode"
},
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.author",
"short": "XDSDocumentEntry.author",
"definition": "Represents the humans and/or machines that authored the document.",
"comments": "Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).",
"min": 1,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Device"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.author"
},
{
"identity": "v2",
"map": "TXA-9-Originator Code/Name (No standard way to indicate a Device in V2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]"
}
]
},
{
"path": "DocumentReference.custodian",
"short": "n/a",
"definition": "Org which maintains the document.",
"comments": "Identifies the logical organization to go to find the current version, where to report issues, etc. This is different from the physical location of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.",
"min": 0,
"max": "0",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Organization"
}
],
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]"
}
]
},
{
"path": "DocumentReference.policyManager",
"short": "XDSDocumentEntry.homeCommunityId",
"definition": "A globally unique identifier for a community with which this document is associated.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A - New participation type required"
}
]
},
{
"path": "DocumentReference.authenticator",
"short": "??",
"definition": "Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator.",
"comments": "Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Practitioner"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.legalAuthenticator"
},
{
"identity": "v2",
"map": "TXA-10-Assigned Document Authenticator"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]"
}
]
},
{
"path": "DocumentReference.created",
"short": "XDSDocumentEntry.creationTime",
"definition": "Represents the time the author created the document in the Document Source.",
"comments": "Creation time is used for tracking, organizing versions and searching. This is the creation time of the document, not the source material on which it is based.",
"min": 1,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "v2",
"map": "TXA-6-Origination Date/Time"
},
{
"identity": "rim",
"map": ".effectiveTime[type=\"TS\"]"
}
]
},
{
"path": "DocumentReference.indexed",
"short": "XDS submission time or XDSDocumentEntry.creationTime if unknown",
"definition": "When this document reference created.",
"comments": "Referencing/indexing time is used for tracking, organizing versions and searching.",
"min": 1,
"max": "1",
"type": [
{
"code": "instant"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "rim",
"map": ".availabilityTime[type=\"TS\"]"
}
]
},
{
"path": "DocumentReference.status",
"short": "implied by XDS workflow",
"definition": "This attribute is always set to Approved as part of the submission of new XDS Documents. It may be changed to Deprecated under the primary responsibility of the Document Source with possible patient supervision. Although XDS supports the ability to delete documents, there is no such state as ???the Document Entry is removed??? (only an audit trail is kept if such a deletion is allowed).",
"comments": "This is the status of the DocumentReference object, which might be independent from the docStatus.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"binding": {
"name": "DocumentReferenceStatus",
"isExtensible": false,
"conformance": "required",
"description": "The status of the document reference",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/document-reference-status"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry status"
},
{
"identity": "v2",
"map": "TXA-19-Document Availability Status"
},
{
"identity": "rim",
"map": "interim: .completionCode=\"IN\" & ./statusCode[isNormalDatatype()]=\"active\";\n\nfinal: .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()]);\n\namended: .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\"];\n\nwithdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]=\"obsolete\""
}
]
},
{
"path": "DocumentReference.docStatus",
"short": "Status of the underlying document.",
"definition": "Status of the underlying document.",
"comments": "The document that is pointed to might be in various lifecycle states.",
"min": 0,
"max": "0",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"name": "ReferredDocumentStatus",
"isExtensible": true,
"conformance": "preferred",
"description": "Status of the underlying document",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/composition-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-17-Document Completion Status"
},
{
"identity": "rim",
"map": ".statusCode"
}
]
},
{
"path": "DocumentReference.relatesTo",
"short": "Relationships that this document has with other document references that already exist",
"definition": "Relationships to other documents.",
"min": 0,
"max": "*",
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship"
}
]
},
{
"path": "DocumentReference.relatesTo.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.relatesTo.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.relatesTo.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.relatesTo.code",
"short": "The type of relationship that this document has with anther document",
"definition": "supercedes | transforms | signs | appends.",
"comments": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"binding": {
"name": "DocumentRelationshipType",
"isExtensible": false,
"conformance": "required",
"description": "The type of relationship between documents",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/document-relationship-type"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry Associations type"
},
{
"identity": "rim",
"map": ".outboundRelationship.typeCode"
}
]
},
{
"path": "DocumentReference.relatesTo.target",
"short": "The target document of this relationship",
"definition": "Target of the relationship.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/DocumentReference"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry Associations reference"
},
{
"identity": "rim",
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id"
}
]
},
{
"path": "DocumentReference.description",
"short": "XDSDocumentEntry.title",
"definition": "Represents the title of the document.",
"comments": "What the document is about, rather than a terse summary of the document. It is commonly the case that records do not have a title and are collectively referred to by the display name of Record code (e.g. a \"consultation\" or \"progress note\").",
"requirements": "Helps humans to assess whether the document is of interest.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.description"
},
{
"identity": "v2",
"map": "TXA-25-Document Title"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text"
}
]
},
{
"path": "DocumentReference.confidentiality",
"short": "XDSDocumentEntry.confidentialityCode",
"definition": "The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain.",
"comments": "The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. \n• [1…1] Confidentiality Security Classification Label Field\n• [0…*] Sensitivity Security Category Label Field\n• [0…*] Compartment Security Category Label Field\n• [0…*] Integrity Security Category Label Field\n• [0…*] Handling Caveat Security Category Field\nIn the HL7 Healthcare Privacy and Security Classification System In the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.",
"requirements": "Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isModifier": true,
"binding": {
"name": "DocumentConfidentiality",
"isExtensible": true,
"conformance": "preferred",
"description": "Codes specifying the level of confidentiality of the composition",
"referenceReference": {
"reference": "http://hl7.org/fhir/v3/vs/Confidentiality"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.confidentialityCode"
},
{
"identity": "v2",
"map": "TXA-18-Document Confidentiality Status"
},
{
"identity": "rim",
"map": ".confidentialityCode"
}
]
},
{
"path": "DocumentReference.content",
"short": "Where to access the document",
"definition": "The document or url to the document along with critical metadata to prove content has integrity.",
"min": 1,
"max": "*",
"type": [
{
"code": "Attachment"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.mimeType\nDocumentEntry.languageCode\nDocumentEntry.URI\nDocumentEntry.size\nDocumentEntry.hash\nDocumentEntry.title"
}
]
},
{
"path": "DocumentReference.content.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.contentType",
"short": "XDSDocumentEntry.mimeType",
"definition": "MIME type of the document in the Repository.",
"requirements": "Processors of the data need to be able to know how to interpret the data.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"exampleCode": "text/plain; charset=UTF-8, image/png",
"binding": {
"name": "MimeType",
"isExtensible": false,
"conformance": "required",
"description": "The mime type of an attachment",
"referenceUri": "http://www.rfc-editor.org/bcp/bcp13.txt"
},
"mapping": [
{
"identity": "v2",
"map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used"
},
{
"identity": "rim",
"map": "./mediaType, ./charset"
}
]
},
{
"path": "DocumentReference.content.language",
"short": "XDSDocumentEntry.languageCode",
"definition": "Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066.",
"requirements": "Users need to be able to choose between the languages in a set of attachments.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
],
"exampleCode": "en-AU",
"binding": {
"name": "Language",
"isExtensible": false,
"conformance": "required",
"description": "A human language",
"referenceUri": "http://tools.ietf.org/html/bcp47"
},
"mapping": [
{
"identity": "rim",
"map": "./language"
}
]
},
{
"path": "DocumentReference.content.data",
"short": "Data inline, base64ed",
"definition": "The actual data of the attachment - a sequence of bytes. In XML, represented using base64.",
"comments": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.",
"requirements": "The data needs to able to be transmitted inline.",
"min": 0,
"max": "1",
"type": [
{
"code": "base64Binary"
}
],
"mapping": [
{
"identity": "v2",
"map": "ED.5"
},
{
"identity": "rim",
"map": "./data"
}
]
},
{
"path": "DocumentReference.content.url",
"short": "repository location (by implication & configuration)",
"definition": "Where to access the document.",
"comments": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.",
"requirements": "The data needs to be transmitted by reference.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
],
"exampleUri": "http://www.acme.com/logo-small.png",
"mapping": [
{
"identity": "v2",
"map": "RP.1+RP.2 - if they refer to a URL (see v2.6)"
},
{
"identity": "rim",
"map": "./reference/literal"
}
]
},
{
"path": "DocumentReference.content.size",
"short": "XDSDocumentEntry.size",
"definition": "Size in bytes of the byte stream that was provided in the Register and Provide Transaction and stored by the XDS Document Repository. This value is computed by the Document Repository and included in the Register Documents Set Transaction.",
"comments": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.",
"requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.",
"min": 0,
"max": "1",
"type": [
{
"code": "integer"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A (needs data type R3 proposal)"
}
]
},
{
"path": "DocumentReference.content.hash",
"short": "XDSDocumentEntry.hash",
"definition": "Hash key of the XDS Document itself.",
"requirements": "Included so that applications can verify that the contents of a location have not changed and so that a signature of the content can implicitly sign the content of an image without having to include the data in the instance or reference the url in the signature.",
"min": 0,
"max": "1",
"type": [
{
"code": "base64Binary"
}
],
"mapping": [
{
"identity": "rim",
"map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]"
}
]
},
{
"path": "DocumentReference.content.title",
"short": "Label to display in place of the data",
"definition": "A label or set of text to display in place of the data.",
"requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
],
"exampleString": "\"Official Corporate Logo\"",
"mapping": [
{
"identity": "rim",
"map": "./title/data"
}
]
},
{
"path": "DocumentReference.context",
"short": "event codes, service Start & Stop time, and facility type",
"definition": "Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type.",
"comments": "These values are primarily added to help with searching for interesting/relevant documents.",
"min": 0,
"max": "1",
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']"
}
]
},
{
"path": "DocumentReference.context.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"synonym": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.context.event",
"short": "XDSDocumentEntry.eventCodeList",
"definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act.",
"comments": "An event can further specialize the act inherent in the type, such as \nwhere it is simply \"Procedure Report\" and the procedure was a \"colonoscopy\". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"name": "DocumentEventType",
"isExtensible": true,
"conformance": "preferred",
"description": "This list of codes represents the main clinical acts being documented",
"referenceReference": {
"reference": "http://hl7.org/fhir/v3/vs/ActCode"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.eventCodeList"
},
{
"identity": "rim",
"map": ".code"
}
]
},
{
"path": "DocumentReference.context.period",
"short": "XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime",
"definition": "The start and stop time of the service being documented took place.",
"min": 1,
"max": "1",
"type": [
{
"code": "Period"
}
],
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.serviceStartTime\nDocumentEntry.serviceStopTime"
},
{
"identity": "rim",
"map": ".effectiveTime"
}
]
},
{
"path": "DocumentReference.context.facilityType",
"short": "XDSDocumentEntry.healthCareFacilityTypeCode",
"definition": "This code represents the type of organizational setting of the clinical encounter during which the documented act occurred.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"binding": {
"name": "DocumentFacilityType",
"isExtensible": true,
"conformance": "example",
"description": "XDS Facility Type",
"referenceReference": {
"reference": "http://hl7.org/fhir/vs/xds-facilitycodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.healthcareFacilityTypeCode"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
}
]
}
]
},
"differential": {
"element": [
{
"path": "DocumentReference",
"name": "DocumentReference",
"short": "XDSDocumentEntry",
"definition": "A reference to a document.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.masterIdentifier",
"short": "XDSDocumentEntry.uniqueId",
"definition": "Globally unique identifier assigned to the document by the creating entity.\nA DocumentEntry representing a single document is identified by the uniqueId attribute; the linkage between DocumentEntry and the Document it represents is made with the uniqueId attribute.\nThis unique identifier may be used in other documents to reference this document.",
"min": 1,
"max": "1",
"type": [
{
"code": "Identifier"
}
]
},
{
"path": "DocumentReference.identifier",
"short": "XDSDocumentEntry.referenceIdList",
"definition": "Other identifiers for the document.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
]
},
{
"path": "DocumentReference.subject",
"short": "XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo",
"definition": "The patientId represents the subject of care of the document. The value of the patientId shall be the same for all new documents of a SubmissionSet. Patient information typically includes: the patient first and last name, sex, and birth date.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Patient"
}
]
},
{
"path": "DocumentReference.type",
"short": "XDSDocumentEntry.typeCode",
"definition": "The code specifying the particular kind of document (e.g., Prescription, Discharge Summary, Report). It is suggested that the XDS Affinity Domain draws these values from a coding scheme providing a coarse level of granularity (about 10 to 100 entries). Shall have a single value.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"path": "DocumentReference.class",
"short": "XDSDocumentEntry.classCode",
"definition": "A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"path": "DocumentReference.format",
"short": "XDSDocumentEntry.formatCode",
"definition": "Code globally uniquely specifying the format of the document. Along with the typeCode, it should provide sufficient information to allow any potential XDS Document Consumer to know if it will be able to process the document. The formatCode shall be sufficiently specific to ensure processing/display by identifying a document encoding, structure and template (e.g., for a CDA Document, the fact that it complies with a CDA schema, possibly a template and the choice of a content-specific style sheet).",
"min": 1,
"max": "1",
"type": [
{
"code": "uri"
}
]
},
{
"path": "DocumentReference.author",
"short": "XDSDocumentEntry.author",
"definition": "Represents the humans and/or machines that authored the document.",
"min": 1,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Device"
}
]
},
{
"path": "DocumentReference.custodian",
"short": "n/a",
"definition": "Org which maintains the document.",
"min": 0,
"max": "0",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Organization"
}
]
},
{
"path": "DocumentReference.policyManager",
"short": "XDSDocumentEntry.homeCommunityId",
"definition": "A globally unique identifier for a community with which this document is associated.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
]
},
{
"path": "DocumentReference.authenticator",
"short": "??",
"definition": "Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/Practitioner"
}
]
},
{
"path": "DocumentReference.created",
"short": "XDSDocumentEntry.creationTime",
"definition": "Represents the time the author created the document in the Document Source.",
"min": 1,
"max": "1",
"type": [
{
"code": "dateTime"
}
]
},
{
"path": "DocumentReference.indexed",
"short": "XDS submission time or XDSDocumentEntry.creationTime if unknown",
"definition": "When this document reference created.",
"min": 1,
"max": "1",
"type": [
{
"code": "instant"
}
]
},
{
"path": "DocumentReference.status",
"short": "implied by XDS workflow",
"definition": "This attribute is always set to Approved as part of the submission of new XDS Documents. It may be changed to Deprecated under the primary responsibility of the Document Source with possible patient supervision. Although XDS supports the ability to delete documents, there is no such state as ???the Document Entry is removed??? (only an audit trail is kept if such a deletion is allowed).",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
]
},
{
"path": "DocumentReference.docStatus",
"short": "Status of the underlying document.",
"definition": "Status of the underlying document.",
"min": 0,
"max": "0",
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"path": "DocumentReference.relatesTo",
"short": "Relationships that this document has with other document references that already exist",
"definition": "Relationships to other documents.",
"min": 0,
"max": "*"
},
{
"path": "DocumentReference.relatesTo.code",
"short": "The type of relationship that this document has with anther document",
"definition": "supercedes | transforms | signs | appends.",
"comments": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
]
},
{
"path": "DocumentReference.relatesTo.target",
"short": "The target document of this relationship",
"definition": "Target of the relationship.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/Profile/DocumentReference"
}
]
},
{
"path": "DocumentReference.description",
"short": "XDSDocumentEntry.title",
"definition": "Represents the title of the document.",
"min": 0,
"max": "1",
"type": [
{
"code": "string"
}
]
},
{
"path": "DocumentReference.confidentiality",
"short": "XDSDocumentEntry.confidentialityCode",
"definition": "The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"path": "DocumentReference.content"
},
{
"path": "DocumentReference.content.contentType",
"short": "XDSDocumentEntry.mimeType",
"definition": "MIME type of the document in the Repository.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
]
},
{
"path": "DocumentReference.content.language",
"short": "XDSDocumentEntry.languageCode",
"definition": "Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066.",
"min": 0,
"max": "1",
"type": [
{
"code": "code"
}
]
},
{
"path": "DocumentReference.content.url",
"short": "repository location (by implication & configuration)",
"definition": "Where to access the document.",
"min": 0,
"max": "1",
"type": [
{
"code": "uri"
}
]
},
{
"path": "DocumentReference.content.size",
"short": "XDSDocumentEntry.size",
"definition": "Size in bytes of the byte stream that was provided in the Register and Provide Transaction and stored by the XDS Document Repository. This value is computed by the Document Repository and included in the Register Documents Set Transaction.",
"min": 0,
"max": "1",
"type": [
{
"code": "integer"
}
]
},
{
"path": "DocumentReference.content.hash",
"short": "XDSDocumentEntry.hash",
"definition": "Hash key of the XDS Document itself.",
"min": 0,
"max": "1",
"type": [
{
"code": "base64Binary"
}
]
},
{
"path": "DocumentReference.context",
"short": "event codes, service Start & Stop time, and facility type",
"definition": "Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type.",
"min": 0,
"max": "1"
},
{
"path": "DocumentReference.context.event",
"short": "XDSDocumentEntry.eventCodeList",
"definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act.",
"min": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
]
},
{
"path": "DocumentReference.context.period",
"short": "XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime",
"definition": "The start and stop time of the service being documented took place.",
"min": 1,
"max": "1",
"type": [
{
"code": "Period"
}
]
},
{
"path": "DocumentReference.context.facilityType",
"short": "XDSDocumentEntry.healthCareFacilityTypeCode",
"definition": "This code represents the type of organizational setting of the clinical encounter during which the documented act occurred.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
]
}
]
}
}
© HL7.org 2011+. FHIR DSTU (v0.4.0-4167) generated on Mon, Feb 23, 2015 09:20+1100.
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