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
DocumentReference
<Profile xmlns="http://hl7.org/fhir"> <id value="xds-documentreference"/> <text> <status value="generated"/> <div xmlns="http://www.w3.org/1999/xhtml"><!-- Snipped for brevity --></div> </text> <url value="http://hl7.org/fhir/Profile/xds-documentreference"/> <name value="XDS profile for Document Reference"/> <publisher value="HL7"/> <contact> <telecom> <system value="url"/> <value value="http://www.hl7.org"/> </telecom> </contact> <description value="XDSDocumentEntry"/> <status value="draft"/> <date value="2012-06-24"/> <type value="DocumentReference"/> <base value="http://hl7.org/fhir/Profile/DocumentReference"/> <snapshot> <element> <path value="DocumentReference"/> <name value="DocumentReference"/> <short value="XDSDocumentEntry"/> <definition value="A reference to a document."/> <comments value="Usually, this is used for documents other than those defined by FHIR."/> <min value="1"/> <max value="1"/> <mapping> <identity value="rim"/> <map value="Document[classCode="DOC" and moodCode="EVN"]"/> </mapping> </element> <element> <path value="DocumentReference.id"/> <short value="Logical id of this artefact"/> <definition value="The logical id of the resource, as used in the url for the resoure. Once assigned, this value never changes."/> <comments value="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 value="0"/> <max value="1"/> <type> <code value="id"/> </type> </element> <element> <path value="DocumentReference.meta"/> <short value="Metadata about the resource"/> <definition value="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 value="0"/> <max value="1"/> <type> <code value="Meta"/> </type> </element> <element> <path value="DocumentReference.implicitRules"/> <short value="A set of rules under which this content was created"/> <definition value="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 value="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 value="0"/> <max value="1"/> <type> <code value="uri"/> </type> <isModifier value="true"/> </element> <element> <path value="DocumentReference.language"/> <short value="Language of the resource content"/> <definition value="The base language in which the resource is written."/> <comments value="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 Not 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 value="0"/> <max value="1"/> <type> <code value="code"/> </type> <binding> <name value="Language"/> <isExtensible value="false"/> <conformance value="required"/> <description value="A human language"/> <referenceUri value="http://tools.ietf.org/html/bcp47"/> </binding> </element> <element> <path value="DocumentReference.text"/> <short value="Text summary of the resource, for human interpretation"/> <definition value="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 value="Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative."/> <synonym value="narrative"/> <synonym value="html"/> <synonym value="xhtml"/> <synonym value="display"/> <min value="0"/> <max value="1"/> <type> <code value="Narrative"/> </type> <condition value="dom-1"/> <mapping> <identity value="rim"/> <map value="Act.text?"/> </mapping> </element> <element> <path value="DocumentReference.contained"/> <short value="Contained, inline Resources"/> <definition value="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 value="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 value="inline resources"/> <synonym value="anonymous resources"/> <synonym value="contained resources"/> <min value="0"/> <max value="*"/> <type> <code value="Resource"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="DocumentReference.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="DocumentReference.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="DocumentReference.masterIdentifier"/> <short value="XDSDocumentEntry.uniqueId"/> <definition value="Globally unique identifier assigned to the document by the creating entity. A 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. This unique identifier may be used in other documents to reference this document."/> <comments value="CDA Document Id extension and root."/> <requirements value="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 value="1"/> <max value="1"/> <type> <code value="Identifier"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.uniqueId"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-12-Unique Document Number"/> </mapping> <mapping> <identity value="rim"/> <map value=".id"/> </mapping> </element> <element> <path value="DocumentReference.identifier"/> <short value="XDSDocumentEntry.referenceIdList"/> <definition value="Other identifiers for the document."/> <comments value="Other identifiers can also include Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDS Workflow Instance Identifiers."/> <min value="0"/> <max value="*"/> <type> <code value="Identifier"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.entryUUID"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-16-Unique Document File Name?"/> </mapping> <mapping> <identity value="rim"/> <map value=".id / .setId"/> </mapping> </element> <element> <path value="DocumentReference.subject"/> <short value="XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Patient"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.patientId DocumentEntry.sourcePatientId DocumentEntry.SourcePatientInfo"/> </mapping> <mapping> <identity value="v2"/> <map value="PID-3-Patient ID List (No standard way to define a Practitioner or Group subject in V2 MDM message)"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="SBJ"].role[typeCode="PAT"]"/> </mapping> </element> <element> <path value="DocumentReference.type"/> <short value="XDSDocumentEntry.typeCode"/> <definition value="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 value="Key metadata element describing the document, used in searching/filtering."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="DocumentType"/> <isExtensible value="true"/> <conformance value="preferred"/> <description value="Type of a composition"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/doc-codes"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry.type"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-2-Document Type"/> </mapping> <mapping> <identity value="rim"/> <map value="./code"/> </mapping> </element> <element> <path value="DocumentReference.class"/> <short value="XDSDocumentEntry.classCode"/> <definition value="A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type."/> <comments value="Helps humans to assess whether the document is of interest when viewing an list of documents."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="DocumentClass"/> <isExtensible value="true"/> <conformance value="example"/> <description value="SubType of a clinical document"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/xds-typecodes"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry.class"/> </mapping> <mapping> <identity value="v2"/> <map value=".outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN&quo t;].code"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN&quo t;].code"/> </mapping> </element> <element> <path value="DocumentReference.format"/> <short value="XDSDocumentEntry.formatCode"/> <definition value="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 value="Helps the processing. Usually is a URN that identifies. For IHE defined Document Content profiles this is a urn issued by IHE."/> <min value="1"/> <max value="1"/> <type> <code value="uri"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.formatCode"/> </mapping> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.author"/> <short value="XDSDocumentEntry.author"/> <definition value="Represents the humans and/or machines that authored the document."/> <comments value="Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant)."/> <min value="1"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Device"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.author"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-9-Originator Code/Name (No standard way to indicate a Device in V2 MDM message)"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUT"].role[classCode="ASSIGNED"]"/> </mapping> </element> <element> <path value="DocumentReference.custodian"/> <short value="n/a"/> <definition value="Org which maintains the document."/> <comments value="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 value="0"/> <max value="0"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Organization"/> </type> <mapping> <identity value="rim"/> <map value=".participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG " and determinerCode="INST"]"/> </mapping> </element> <element> <path value="DocumentReference.policyManager"/> <short value="XDSDocumentEntry.homeCommunityId"/> <definition value="A globally unique identifier for a community with which this document is associated."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> <mapping> <identity value="rim"/> <map value="N/A - New participation type required"/> </mapping> </element> <element> <path value="DocumentReference.authenticator"/> <short value="??"/> <definition value="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 value="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 value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Practitioner"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.legalAuthenticator"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-10-Assigned Document Authenticator"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]"/> </mapping> </element> <element> <path value="DocumentReference.created"/> <short value="XDSDocumentEntry.creationTime"/> <definition value="Represents the time the author created the document in the Document Source."/> <comments value="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 value="1"/> <max value="1"/> <type> <code value="dateTime"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.submissionTime"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-6-Origination Date/Time"/> </mapping> <mapping> <identity value="rim"/> <map value=".effectiveTime[type="TS"]"/> </mapping> </element> <element> <path value="DocumentReference.indexed"/> <short value="XDS submission time or XDSDocumentEntry.creationTime if unknown"/> <definition value="When this document reference created."/> <comments value="Referencing/indexing time is used for tracking, organizing versions and searching."/> <min value="1"/> <max value="1"/> <type> <code value="instant"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.submissionTime"/> </mapping> <mapping> <identity value="rim"/> <map value=".availabilityTime[type="TS"]"/> </mapping> </element> <element> <path value="DocumentReference.status"/> <short value="implied by XDS workflow"/> <definition value="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 value="This is the status of the DocumentReference object, which might be independent from the docStatus."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> <isModifier value="true"/> <binding> <name value="DocumentReferenceStatus"/> <isExtensible value="false"/> <conformance value="required"/> <description value="The status of the document reference"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/document-reference-status"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry status"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-19-Document Availability Status"/> </mapping> <mapping> <identity value="rim"/> <map value="interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete&q uot; and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[su bsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocum ent", 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[isNo rmalDatatype()]="obsolete""/> </mapping> </element> <element> <path value="DocumentReference.docStatus"/> <short value="Status of the underlying document."/> <definition value="Status of the underlying document."/> <comments value="The document that is pointed to might be in various lifecycle states."/> <min value="0"/> <max value="0"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="ReferredDocumentStatus"/> <isExtensible value="true"/> <conformance value="preferred"/> <description value="Status of the underlying document"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/composition-status"/> </referenceReference> </binding> <mapping> <identity value="v2"/> <map value="TXA-17-Document Completion Status"/> </mapping> <mapping> <identity value="rim"/> <map value=".statusCode"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo"/> <short value="Relationships that this document has with other document references that already exist"/> <definition value="Relationships to other documents."/> <min value="0"/> <max value="*"/> <isModifier value="true"/> <mapping> <identity value="rim"/> <map value=".outboundRelationship"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <synonym value="modifiers"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo.code"/> <short value="The type of relationship that this document has with anther document"/> <definition value="supercedes | transforms | signs | appends."/> <comments value="If this document appends another document, then the document cannot be fully understood without also accessing the referenced document."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> <binding> <name value="DocumentRelationshipType"/> <isExtensible value="false"/> <conformance value="required"/> <description value="The type of relationship between documents"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/document-relationship-type"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry Associations type"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship.typeCode"/> </mapping> </element> <element> <path value="DocumentReference.relatesTo.target"/> <short value="The target document of this relationship"/> <definition value="Target of the relationship."/> <min value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/DocumentReference"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry Associations reference"/> </mapping> <mapping> <identity value="rim"/> <map value=".target[classCode="DOC", moodCode="EVN"].id"/> </mapping> </element> <element> <path value="DocumentReference.description"/> <short value="XDSDocumentEntry.title"/> <definition value="Represents the title of the document."/> <comments value="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 value="Helps humans to assess whether the document is of interest."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.description"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-25-Document Title"/> </mapping> <mapping> <identity value="rim"/> <map value=".outboundRelationship[typeCode="SUBJ"].target.text"/> </mapping> </element> <element> <path value="DocumentReference.confidentiality"/> <short value="XDSDocumentEntry.confidentialityCode"/> <definition value="The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain."/> <comments value="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. • [1…1] Confidentiality Security Classification Label Field • [0…*] Sensitivity Security Category Label Field • [0…*] Compartment Security Category Label Field • [0…*] Integrity Security Category Label Field • [0…*] Handling Caveat Security Category Field In 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 value="Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <isModifier value="true"/> <binding> <name value="DocumentConfidentiality"/> <isExtensible value="true"/> <conformance value="preferred"/> <description value="Codes specifying the level of confidentiality of the composition"/> <referenceReference> <reference value="http://hl7.org/fhir/v3/vs/Confidentiality"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry.confidentialityCode"/> </mapping> <mapping> <identity value="v2"/> <map value="TXA-18-Document Confidentiality Status"/> </mapping> <mapping> <identity value="rim"/> <map value=".confidentialityCode"/> </mapping> </element> <element> <path value="DocumentReference.content"/> <short value="Where to access the document"/> <definition value="The document or url to the document along with critical metadata to prove content has integrity."/> <min value="1"/> <max value="*"/> <type> <code value="Attachment"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title"/> </mapping> </element> <element> <path value="DocumentReference.content.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.content.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.content.contentType"/> <short value="XDSDocumentEntry.mimeType"/> <definition value="MIME type of the document in the Repository."/> <requirements value="Processors of the data need to be able to know how to interpret the data."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> <exampleCode value="text/plain; charset=UTF-8, image/png"/> <binding> <name value="MimeType"/> <isExtensible value="false"/> <conformance value="required"/> <description value="The mime type of an attachment"/> <referenceUri value="http://www.rfc-editor.org/bcp/bcp13.txt"/> </binding> <mapping> <identity value="v2"/> <map value="ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used"/> </mapping> <mapping> <identity value="rim"/> <map value="./mediaType, ./charset"/> </mapping> </element> <element> <path value="DocumentReference.content.language"/> <short value="XDSDocumentEntry.languageCode"/> <definition value="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 value="Users need to be able to choose between the languages in a set of attachments."/> <min value="0"/> <max value="1"/> <type> <code value="code"/> </type> <exampleCode value="en-AU"/> <binding> <name value="Language"/> <isExtensible value="false"/> <conformance value="required"/> <description value="A human language"/> <referenceUri value="http://tools.ietf.org/html/bcp47"/> </binding> <mapping> <identity value="rim"/> <map value="./language"/> </mapping> </element> <element> <path value="DocumentReference.content.data"/> <short value="Data inline, base64ed"/> <definition value="The actual data of the attachment - a sequence of bytes. In XML, represented using base64."/> <comments value="The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON."/> <requirements value="The data needs to able to be transmitted inline."/> <min value="0"/> <max value="1"/> <type> <code value="base64Binary"/> </type> <mapping> <identity value="v2"/> <map value="ED.5"/> </mapping> <mapping> <identity value="rim"/> <map value="./data"/> </mapping> </element> <element> <path value="DocumentReference.content.url"/> <short value="repository location (by implication & configuration)"/> <definition value="Where to access the document."/> <comments value="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 value="The data needs to be transmitted by reference."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> <exampleUri value="http://www.acme.com/logo-small.png"/> <mapping> <identity value="v2"/> <map value="RP.1+RP.2 - if they refer to a URL (see v2.6)"/> </mapping> <mapping> <identity value="rim"/> <map value="./reference/literal"/> </mapping> </element> <element> <path value="DocumentReference.content.size"/> <short value="XDSDocumentEntry.size"/> <definition value="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 value="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 value="Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all."/> <min value="0"/> <max value="1"/> <type> <code value="integer"/> </type> <mapping> <identity value="rim"/> <map value="N/A (needs data type R3 proposal)"/> </mapping> </element> <element> <path value="DocumentReference.content.hash"/> <short value="XDSDocumentEntry.hash"/> <definition value="Hash key of the XDS Document itself."/> <requirements value="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 value="0"/> <max value="1"/> <type> <code value="base64Binary"/> </type> <mapping> <identity value="rim"/> <map value=".integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"]"/> </mapping> </element> <element> <path value="DocumentReference.content.title"/> <short value="Label to display in place of the data"/> <definition value="A label or set of text to display in place of the data."/> <requirements value="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 value="0"/> <max value="1"/> <type> <code value="string"/> </type> <exampleString value=""Official Corporate Logo""/> <mapping> <identity value="rim"/> <map value="./title/data"/> </mapping> </element> <element> <path value="DocumentReference.context"/> <short value="event codes, service Start & Stop time, and facility type"/> <definition value="Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type."/> <comments value="These values are primarily added to help with searching for interesting/relevant documents."/> <min value="0"/> <max value="1"/> <mapping> <identity value="rim"/> <map value="outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']"/> </mapping> </element> <element> <path value="DocumentReference.context.id"/> <representation value="xmlAttr"/> <short value="xml:id (or equivalent in JSON)"/> <definition value="unique id for the element within a resource (for internal references)."/> <min value="0"/> <max value="1"/> <type> <code value="id"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.context.extension"/> <short value="Additional Content defined by implementations"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="n/a"/> </mapping> </element> <element> <path value="DocumentReference.context.modifierExtension"/> <short value="Extensions that cannot be ignored"/> <definition value="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 value="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 value="extensions"/> <synonym value="user content"/> <synonym value="modifiers"/> <min value="0"/> <max value="*"/> <type> <code value="Extension"/> </type> <mapping> <identity value="rim"/> <map value="N/A"/> </mapping> </element> <element> <path value="DocumentReference.context.event"/> <short value="XDSDocumentEntry.eventCodeList"/> <definition value="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 value="An event can further specialize the act inherent in the type, such as where 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 value="0"/> <max value="*"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="DocumentEventType"/> <isExtensible value="true"/> <conformance value="preferred"/> <description value="This list of codes represents the main clinical acts being documented"/> <referenceReference> <reference value="http://hl7.org/fhir/v3/vs/ActCode"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry.eventCodeList"/> </mapping> <mapping> <identity value="rim"/> <map value=".code"/> </mapping> </element> <element> <path value="DocumentReference.context.period"/> <short value="XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime"/> <definition value="The start and stop time of the service being documented took place."/> <min value="1"/> <max value="1"/> <type> <code value="Period"/> </type> <mapping> <identity value="xds"/> <map value="DocumentEntry.serviceStartTime DocumentEntry.serviceStopTime"/> </mapping> <mapping> <identity value="rim"/> <map value=".effectiveTime"/> </mapping> </element> <element> <path value="DocumentReference.context.facilityType"/> <short value="XDSDocumentEntry.healthCareFacilityTypeCode"/> <definition value="This code represents the type of organizational setting of the clinical encounter during which the documented act occurred."/> <min value="0"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> <binding> <name value="DocumentFacilityType"/> <isExtensible value="true"/> <conformance value="example"/> <description value="XDS Facility Type"/> <referenceReference> <reference value="http://hl7.org/fhir/vs/xds-facilitycodes"/> </referenceReference> </binding> <mapping> <identity value="xds"/> <map value="DocumentEntry.healthcareFacilityTypeCode"/> </mapping> <mapping> <identity value="rim"/> <map value=".participation[typeCode="LOC"].role[classCode="DSDLOC"].code"/> </mapping> </element> </snapshot> <differential> <element> <path value="DocumentReference"/> <name value="DocumentReference"/> <short value="XDSDocumentEntry"/> <definition value="A reference to a document."/> <min value="1"/> <max value="1"/> </element> <element> <path value="DocumentReference.masterIdentifier"/> <short value="XDSDocumentEntry.uniqueId"/> <definition value="Globally unique identifier assigned to the document by the creating entity. A 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. This unique identifier may be used in other documents to reference this document."/> <min value="1"/> <max value="1"/> <type> <code value="Identifier"/> </type> </element> <element> <path value="DocumentReference.identifier"/> <short value="XDSDocumentEntry.referenceIdList"/> <definition value="Other identifiers for the document."/> <min value="0"/> <max value="*"/> <type> <code value="Identifier"/> </type> </element> <element> <path value="DocumentReference.subject"/> <short value="XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Patient"/> </type> </element> <element> <path value="DocumentReference.type"/> <short value="XDSDocumentEntry.typeCode"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> </element> <element> <path value="DocumentReference.class"/> <short value="XDSDocumentEntry.classCode"/> <definition value="A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> </element> <element> <path value="DocumentReference.format"/> <short value="XDSDocumentEntry.formatCode"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="uri"/> </type> </element> <element> <path value="DocumentReference.author"/> <short value="XDSDocumentEntry.author"/> <definition value="Represents the humans and/or machines that authored the document."/> <min value="1"/> <max value="*"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Practitioner"/> </type> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Device"/> </type> </element> <element> <path value="DocumentReference.custodian"/> <short value="n/a"/> <definition value="Org which maintains the document."/> <min value="0"/> <max value="0"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Organization"/> </type> </element> <element> <path value="DocumentReference.policyManager"/> <short value="XDSDocumentEntry.homeCommunityId"/> <definition value="A globally unique identifier for a community with which this document is associated."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> </element> <element> <path value="DocumentReference.authenticator"/> <short value="??"/> <definition value="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 value="0"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/Practitioner"/> </type> </element> <element> <path value="DocumentReference.created"/> <short value="XDSDocumentEntry.creationTime"/> <definition value="Represents the time the author created the document in the Document Source."/> <min value="1"/> <max value="1"/> <type> <code value="dateTime"/> </type> </element> <element> <path value="DocumentReference.indexed"/> <short value="XDS submission time or XDSDocumentEntry.creationTime if unknown"/> <definition value="When this document reference created."/> <min value="1"/> <max value="1"/> <type> <code value="instant"/> </type> </element> <element> <path value="DocumentReference.status"/> <short value="implied by XDS workflow"/> <definition value="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 value="1"/> <max value="1"/> <type> <code value="code"/> </type> </element> <element> <path value="DocumentReference.docStatus"/> <short value="Status of the underlying document."/> <definition value="Status of the underlying document."/> <min value="0"/> <max value="0"/> <type> <code value="CodeableConcept"/> </type> </element> <element> <path value="DocumentReference.relatesTo"/> <short value="Relationships that this document has with other document references that already exist"/> <definition value="Relationships to other documents."/> <min value="0"/> <max value="*"/> </element> <element> <path value="DocumentReference.relatesTo.code"/> <short value="The type of relationship that this document has with anther document"/> <definition value="supercedes | transforms | signs | appends."/> <comments value="If this document appends another document, then the document cannot be fully understood without also accessing the referenced document."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> </element> <element> <path value="DocumentReference.relatesTo.target"/> <short value="The target document of this relationship"/> <definition value="Target of the relationship."/> <min value="1"/> <max value="1"/> <type> <code value="Reference"/> <profile value="http://hl7.org/fhir/Profile/DocumentReference"/> </type> </element> <element> <path value="DocumentReference.description"/> <short value="XDSDocumentEntry.title"/> <definition value="Represents the title of the document."/> <min value="0"/> <max value="1"/> <type> <code value="string"/> </type> </element> <element> <path value="DocumentReference.confidentiality"/> <short value="XDSDocumentEntry.confidentialityCode"/> <definition value="The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain."/> <min value="1"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> </element> <element> <path value="DocumentReference.content"/> </element> <element> <path value="DocumentReference.content.contentType"/> <short value="XDSDocumentEntry.mimeType"/> <definition value="MIME type of the document in the Repository."/> <min value="1"/> <max value="1"/> <type> <code value="code"/> </type> </element> <element> <path value="DocumentReference.content.language"/> <short value="XDSDocumentEntry.languageCode"/> <definition value="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 value="0"/> <max value="1"/> <type> <code value="code"/> </type> </element> <element> <path value="DocumentReference.content.url"/> <short value="repository location (by implication & configuration)"/> <definition value="Where to access the document."/> <min value="0"/> <max value="1"/> <type> <code value="uri"/> </type> </element> <element> <path value="DocumentReference.content.size"/> <short value="XDSDocumentEntry.size"/> <definition value="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 value="0"/> <max value="1"/> <type> <code value="integer"/> </type> </element> <element> <path value="DocumentReference.content.hash"/> <short value="XDSDocumentEntry.hash"/> <definition value="Hash key of the XDS Document itself."/> <min value="0"/> <max value="1"/> <type> <code value="base64Binary"/> </type> </element> <element> <path value="DocumentReference.context"/> <short value="event codes, service Start & Stop time, and facility type"/> <definition value="Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type."/> <min value="0"/> <max value="1"/> </element> <element> <path value="DocumentReference.context.event"/> <short value="XDSDocumentEntry.eventCodeList"/> <definition value="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 value="0"/> <max value="*"/> <type> <code value="CodeableConcept"/> </type> </element> <element> <path value="DocumentReference.context.period"/> <short value="XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime"/> <definition value="The start and stop time of the service being documented took place."/> <min value="1"/> <max value="1"/> <type> <code value="Period"/> </type> </element> <element> <path value="DocumentReference.context.facilityType"/> <short value="XDSDocumentEntry.healthCareFacilityTypeCode"/> <definition value="This code represents the type of organizational setting of the clinical encounter during which the documented act occurred."/> <min value="0"/> <max value="1"/> <type> <code value="CodeableConcept"/> </type> </element> </differential> </Profile>