STU 3 Ballot
FoundationThis page is part of the FHIR Specification (v1.6.0: STU 3 Ballot 4). The current version which supercedes this version is 5.0.0. For a full list of available versions, see the Directory of published versions 
. Page versions: R5 R4B R4 R3 R2
StructureDefinition for documentreference
{
"resourceType": "StructureDefinition",
"id": "DocumentReference",
"meta": {
"lastUpdated": "2016-08-11T17:02:54.322+10:00"
},
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 2
}
],
"url": "http://hl7.org/fhir/StructureDefinition/DocumentReference",
"name": "DocumentReference",
"status": "draft",
"publisher": "Health Level Seven International (Structured Documents)",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://hl7.org/fhir"
}
]
},
{
"telecom": [
{
"system": "other",
"value": "http://www.hl7.org/Special/committees/structure/index.cfm"
}
]
}
],
"date": "2016-08-11T17:02:54+10:00",
"description": "Base StructureDefinition for DocumentReference Resource",
"fhirVersion": "1.6.0",
"mapping": [
{
"identity": "rim",
"uri": "http://hl7.org/v3",
"name": "RIM Mapping"
},
{
"identity": "w5",
"uri": "http://hl7.org/fhir/w5",
"name": "W5 Mapping"
},
{
"identity": "v2",
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping"
},
{
"identity": "xds",
"uri": "http://ihe.net/xds",
"name": "XDS metadata equivalent"
}
],
"kind": "resource",
"abstract": false,
"type": "DocumentReference",
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource",
"derivation": "specialization",
"snapshot": {
"element": [
{
"id": "DocumentReference",
"path": "DocumentReference",
"short": "A reference to a document",
"definition": "A reference to a document .",
"comments": "Usually, this is used for documents other than those defined by FHIR.",
"min": 0,
"max": "*",
"constraint": [
{
"key": "dom-2",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources",
"expression": "contained.contained.empty()",
"xpath": "not(parent::f:contained and f:contained)"
},
{
"key": "dom-1",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL NOT contain any narrative",
"expression": "contained.text.empty()",
"xpath": "not(parent::f:contained and f:text)"
},
{
"key": "dom-4",
"severity": "error",
"human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated",
"expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()",
"xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))"
},
{
"key": "dom-3",
"severity": "error",
"human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource",
"expression": "contained.where(('#'+id in %resource.descendants().reference).not()).empty()",
"xpath": "not(exists(for $id in f:contained/*/@id return $id[not(ancestor::f:contained/parent::*/descendant::f:reference/@value=concat('#', $id))]))"
}
],
"mapping": [
{
"identity": "rim",
"map": "Entity. Role, or Act"
},
{
"identity": "rim",
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]"
},
{
"identity": "w5",
"map": "infrastructure.documents"
}
]
},
{
"id": "DocumentReference.id",
"path": "DocumentReference.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. 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.",
"min": 0,
"max": "1",
"base": {
"path": "Resource.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"id": "DocumentReference.meta",
"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",
"base": {
"path": "Resource.meta",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"id": "DocumentReference.implicitRules",
"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",
"base": {
"path": "Resource.implicitRules",
"min": 0,
"max": "*"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"id": "DocumentReference.language",
"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 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": 0,
"max": "1",
"base": {
"path": "Resource.language",
"min": 0,
"max": "*"
},
"type": [
{
"code": "code"
}
],
"binding": {
"extension": [
{
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet",
"valueReference": {
"reference": "http://hl7.org/fhir/ValueSet/all-languages"
}
}
],
"strength": "extensible",
"description": "A human language.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/languages"
}
}
},
{
"id": "DocumentReference.text",
"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. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded in formation is added later.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DomainResource.text",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"id": "DocumentReference.contained",
"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.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.extension",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.modifierExtension",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DomainResource.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.masterIdentifier",
"path": "DocumentReference.masterIdentifier",
"short": "Master Version Specific Identifier",
"definition": "Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the 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": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-12"
},
{
"identity": "rim",
"map": ".id"
},
{
"identity": "xds",
"map": "DocumentEntry.uniqueId"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "DocumentReference.identifier",
"path": "DocumentReference.identifier",
"short": "Other identifiers for the document",
"definition": "Other identifiers associated with the document, including version independent identifiers.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-16?"
},
{
"identity": "rim",
"map": ".id / .setId"
},
{
"identity": "xds",
"map": "DocumentEntry.entryUUID"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "DocumentReference.subject",
"path": "DocumentReference.subject",
"short": "Who/what is the subject of the document",
"definition": "Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Group"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.patientId"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "DocumentReference.type",
"path": "DocumentReference.type",
"short": "Kind of document (LOINC if possible)",
"definition": "Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.",
"comments": "Key metadata element describing the document, used in searching/filtering.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Precise type of clinical document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-2"
},
{
"identity": "rim",
"map": "./code"
},
{
"identity": "xds",
"map": "DocumentEntry.type"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "DocumentReference.class",
"path": "DocumentReference.class",
"short": "Categorization of document",
"definition": "A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.",
"comments": "This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).",
"requirements": "Helps humans to assess whether the document is of interest when viewing a list of documents.",
"alias": [
"kind"
],
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "High-level kind of a clinical document at a macro level.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-classcodes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "DocumentReference.author",
"path": "DocumentReference.author",
"short": "Who and/or what authored the document",
"definition": "Identifies who is responsible for adding the information to the document.",
"comments": "Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "DocumentReference.custodian",
"path": "DocumentReference.custodian",
"short": "Organization which maintains the document",
"definition": "Identifies the organization or group who is responsible for ongoing maintenance of and access to 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": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]"
}
]
},
{
"id": "DocumentReference.authenticator",
"path": "DocumentReference.authenticator",
"short": "Who/what authenticated the document",
"definition": "Which person or organization authenticates that this document is valid.",
"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/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-10"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.legalAuthenticator"
},
{
"identity": "w5",
"map": "who.witness"
}
]
},
{
"id": "DocumentReference.created",
"path": "DocumentReference.created",
"short": "Document creation time",
"definition": "When the document was created.",
"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": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-6"
},
{
"identity": "rim",
"map": ".effectiveTime[type=\"TS\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "DocumentReference.indexed",
"path": "DocumentReference.indexed",
"short": "When this document reference created",
"definition": "When the document reference was created.",
"comments": "Referencing/indexing time is used for tracking, organizing versions and searching.",
"min": 1,
"max": "1",
"type": [
{
"code": "instant"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".availabilityTime[type=\"TS\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "DocumentReference.status",
"path": "DocumentReference.status",
"short": "current | superseded | entered-in-error",
"definition": "The status of this document reference.",
"comments": "This is the status of the DocumentReference object, which might be independent from the docStatus element.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The status of the document reference.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-reference-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-19"
},
{
"identity": "rim",
"map": "interim: .completionCode=\"IN\" & ./statusCode[isNormalDatatype()]=\"active\"; final: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and not(./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct()]); amended: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and ./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct() and statusCode=\"completed\"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]=\"obsolete\""
},
{
"identity": "xds",
"map": "DocumentEntry status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "DocumentReference.docStatus",
"path": "DocumentReference.docStatus",
"short": "preliminary | final | appended | amended | entered-in-error",
"definition": "The status of the underlying document.",
"comments": "The document that is pointed to might be in various lifecycle states.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Status of the underlying document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/composition-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-17"
},
{
"identity": "rim",
"map": ".statusCode"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "DocumentReference.relatesTo",
"path": "DocumentReference.relatesTo",
"short": "Relationships to other documents",
"definition": "Relationships that this document has with other document references that already exist.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship"
}
]
},
{
"id": "DocumentReference.relatesTo.id",
"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). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.relatesTo.extension",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.relatesTo.modifierExtension",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.relatesTo.code",
"path": "DocumentReference.relatesTo.code",
"short": "replaces | transforms | signs | appends",
"definition": "The type of relationship that this document has with anther document.",
"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"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "The type of relationship between documents.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-relationship-type"
}
},
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship.typeCode"
},
{
"identity": "xds",
"map": "DocumentEntry Associations type"
}
]
},
{
"id": "DocumentReference.relatesTo.target",
"path": "DocumentReference.relatesTo.target",
"short": "Target of the relationship",
"definition": "The target document of this relationship.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/DocumentReference"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id"
},
{
"identity": "xds",
"map": "DocumentEntry Associations reference"
}
]
},
{
"id": "DocumentReference.description",
"path": "DocumentReference.description",
"short": "Human-readable description (title)",
"definition": "Human-readable description of the source document. This is sometimes known as the \"title\".",
"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"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-25"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text"
},
{
"identity": "xds",
"map": "DocumentEntry.description"
}
]
},
{
"id": "DocumentReference.securityLabel",
"path": "DocumentReference.securityLabel",
"short": "Document security-tags",
"definition": "A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the \"reference\" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.",
"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. 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": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "extensible",
"description": "Security Labels from the Healthcare Privacy and Security Classification System.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/security-labels"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-18"
},
{
"identity": "rim",
"map": ".confidentialityCode"
},
{
"identity": "xds",
"map": "DocumentEntry.confidentialityCode"
}
]
},
{
"id": "DocumentReference.content",
"path": "DocumentReference.content",
"short": "Document referenced",
"definition": "The document and format referenced. There may be multiple content element repetitions, each with a different format.",
"min": 1,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "document.text"
}
]
},
{
"id": "DocumentReference.content.id",
"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). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.content.extension",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.content.modifierExtension",
"path": "DocumentReference.content.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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.content.attachment",
"path": "DocumentReference.content.attachment",
"short": "Where to access the document",
"definition": "The document or url of the document along with critical metadata to prove content has integrity.",
"min": 1,
"max": "1",
"type": [
{
"code": "Attachment"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-3 for mime type"
},
{
"identity": "rim",
"map": "document.text"
},
{
"identity": "xds",
"map": "DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title"
}
]
},
{
"id": "DocumentReference.content.format",
"path": "DocumentReference.content.format",
"short": "Format/content rules for the document",
"definition": "An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.",
"comments": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Document Format Codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/formatcodes"
}
},
"mapping": [
{
"identity": "rim",
"map": "document.text"
},
{
"identity": "xds",
"map": "DocumentEntry.formatCode"
}
]
},
{
"id": "DocumentReference.context",
"path": "DocumentReference.context",
"short": "Clinical context of document",
"definition": "The clinical context in which the document was prepared.",
"comments": "These values are primarily added to help with searching for interesting/relevant documents.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']"
}
]
},
{
"id": "DocumentReference.context.id",
"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). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.context.extension",
"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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.context.modifierExtension",
"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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.context.encounter",
"path": "DocumentReference.context.encounter",
"short": "Context of the document content",
"definition": "Describes the clinical encounter or type of care that the document content is associated with.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"id": "DocumentReference.context.event",
"path": "DocumentReference.context.event",
"short": "Main Clinical Acts Documented",
"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 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": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "This list of codes represents the main clinical acts being documented.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActCode"
}
},
"mapping": [
{
"identity": "rim",
"map": ".code"
},
{
"identity": "xds",
"map": "DocumentEntry.eventCodeList"
}
]
},
{
"id": "DocumentReference.context.period",
"path": "DocumentReference.context.period",
"short": "Time of service that is being documented",
"definition": "The time period over which the service that is described by the document was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".effectiveTime"
},
{
"identity": "xds",
"map": "DocumentEntry.serviceStartTime DocumentEntry.serviceStopTime"
}
]
},
{
"id": "DocumentReference.context.facilityType",
"path": "DocumentReference.context.facilityType",
"short": "Kind of facility where patient was seen",
"definition": "The kind of facility where the patient was seen.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "XDS Facility Type.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-facilitycodes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.healthcareFacilityTypeCode"
}
]
},
{
"id": "DocumentReference.context.practiceSetting",
"path": "DocumentReference.context.practiceSetting",
"short": "Additional details about where the content was created (e.g. clinical specialty)",
"definition": "This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.",
"comments": "The value set for this content has an example binding because it is a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR and XDM for Direct Messaging Specification, Version 1), as well as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * XDS Connect-a-thon practiceSettingCode.",
"requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Additional details about where the content was created (e.g. clinical specialty).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-practice-codes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.practiceSettingCode"
}
]
},
{
"id": "DocumentReference.context.sourcePatientInfo",
"path": "DocumentReference.context.sourcePatientInfo",
"short": "Patient demographics from source",
"definition": "The Patient Information as known when the document was published. May be a reference to a version specific, or contained.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.sourcePatientInfo DocumentEntry.sourcePatientId"
}
]
},
{
"id": "DocumentReference.context.related",
"path": "DocumentReference.context.related",
"short": "Related identifiers or resources",
"definition": "Related identifiers or resources associated with the DocumentReference.",
"comments": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]"
},
{
"identity": "xds",
"map": "DocumentEntry.referenceIdList"
}
]
},
{
"id": "DocumentReference.context.related.id",
"path": "DocumentReference.context.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.",
"min": 0,
"max": "1",
"base": {
"path": "Element.id",
"min": 0,
"max": "*"
},
"type": [
{
"code": "string"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.context.related.extension",
"path": "DocumentReference.context.related.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.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Element.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"id": "DocumentReference.context.related.modifierExtension",
"path": "DocumentReference.context.related.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.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "BackboneElement.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"id": "DocumentReference.context.related.identifier",
"path": "DocumentReference.context.related.identifier",
"short": "Identifier of related objects or events",
"definition": "Related identifier to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order numbers, accession numbers, XDW workflow numbers.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct] .id"
}
]
},
{
"id": "DocumentReference.context.related.ref",
"path": "DocumentReference.context.related.ref",
"short": "Related Resource",
"definition": "Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order, DiagnosticRequest, Procedure, EligibilityRequest, etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct].text.reference"
}
]
}
]
},
"differential": {
"element": [
{
"id": "DocumentReference",
"path": "DocumentReference",
"short": "A reference to a document",
"definition": "A reference to a document .",
"comments": "Usually, this is used for documents other than those defined by FHIR.",
"min": 0,
"max": "*",
"mapping": [
{
"identity": "rim",
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]"
},
{
"identity": "w5",
"map": "infrastructure.documents"
}
]
},
{
"id": "DocumentReference.masterIdentifier",
"path": "DocumentReference.masterIdentifier",
"short": "Master Version Specific Identifier",
"definition": "Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the 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": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-12"
},
{
"identity": "rim",
"map": ".id"
},
{
"identity": "xds",
"map": "DocumentEntry.uniqueId"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "DocumentReference.identifier",
"path": "DocumentReference.identifier",
"short": "Other identifiers for the document",
"definition": "Other identifiers associated with the document, including version independent identifiers.",
"min": 0,
"max": "*",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-16?"
},
{
"identity": "rim",
"map": ".id / .setId"
},
{
"identity": "xds",
"map": "DocumentEntry.entryUUID"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"id": "DocumentReference.subject",
"path": "DocumentReference.subject",
"short": "Who/what is the subject of the document",
"definition": "Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Group"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.patientId"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"id": "DocumentReference.type",
"path": "DocumentReference.type",
"short": "Kind of document (LOINC if possible)",
"definition": "Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.",
"comments": "Key metadata element describing the document, used in searching/filtering.",
"min": 1,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Precise type of clinical document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-2"
},
{
"identity": "rim",
"map": "./code"
},
{
"identity": "xds",
"map": "DocumentEntry.type"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "DocumentReference.class",
"path": "DocumentReference.class",
"short": "Categorization of document",
"definition": "A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.",
"comments": "This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).",
"requirements": "Helps humans to assess whether the document is of interest when viewing a list of documents.",
"alias": [
"kind"
],
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "High-level kind of a clinical document at a macro level.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-classcodes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.class"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"id": "DocumentReference.author",
"path": "DocumentReference.author",
"short": "Who and/or what authored the document",
"definition": "Identifies who is responsible for adding the information to the document.",
"comments": "Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).",
"min": 0,
"max": "*",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Device"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/RelatedPerson"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.author"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"id": "DocumentReference.custodian",
"path": "DocumentReference.custodian",
"short": "Organization which maintains the document",
"definition": "Identifies the organization or group who is responsible for ongoing maintenance of and access to 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": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]"
}
]
},
{
"id": "DocumentReference.authenticator",
"path": "DocumentReference.authenticator",
"short": "Who/what authenticated the document",
"definition": "Which person or organization authenticates that this document is valid.",
"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/StructureDefinition/Practitioner"
},
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Organization"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-10"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.legalAuthenticator"
},
{
"identity": "w5",
"map": "who.witness"
}
]
},
{
"id": "DocumentReference.created",
"path": "DocumentReference.created",
"short": "Document creation time",
"definition": "When the document was created.",
"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": 0,
"max": "1",
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-6"
},
{
"identity": "rim",
"map": ".effectiveTime[type=\"TS\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"id": "DocumentReference.indexed",
"path": "DocumentReference.indexed",
"short": "When this document reference created",
"definition": "When the document reference was created.",
"comments": "Referencing/indexing time is used for tracking, organizing versions and searching.",
"min": 1,
"max": "1",
"type": [
{
"code": "instant"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".availabilityTime[type=\"TS\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"id": "DocumentReference.status",
"path": "DocumentReference.status",
"short": "current | superseded | entered-in-error",
"definition": "The status of this document reference.",
"comments": "This is the status of the DocumentReference object, which might be independent from the docStatus element.",
"min": 1,
"max": "1",
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The status of the document reference.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-reference-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-19"
},
{
"identity": "rim",
"map": "interim: .completionCode=\"IN\" & ./statusCode[isNormalDatatype()]=\"active\"; final: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and not(./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct()]); amended: .completionCode=\"AU\" && ./statusCode[isNormalDatatype()]=\"complete\" and ./inboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()]/source[subsumesCode(\"ActClass#CACT\") and moodCode=\"EVN\" and domainMember(\"ReviseDocument\", code) and isNormalAct() and statusCode=\"completed\"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]=\"obsolete\""
},
{
"identity": "xds",
"map": "DocumentEntry status"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "DocumentReference.docStatus",
"path": "DocumentReference.docStatus",
"short": "preliminary | final | appended | amended | entered-in-error",
"definition": "The status of the underlying document.",
"comments": "The document that is pointed to might be in various lifecycle states.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Status of the underlying document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/composition-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-17"
},
{
"identity": "rim",
"map": ".statusCode"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"id": "DocumentReference.relatesTo",
"path": "DocumentReference.relatesTo",
"short": "Relationships to other documents",
"definition": "Relationships that this document has with other document references that already exist.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship"
}
]
},
{
"id": "DocumentReference.relatesTo.code",
"path": "DocumentReference.relatesTo.code",
"short": "replaces | transforms | signs | appends",
"definition": "The type of relationship that this document has with anther document.",
"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"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "The type of relationship between documents.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-relationship-type"
}
},
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship.typeCode"
},
{
"identity": "xds",
"map": "DocumentEntry Associations type"
}
]
},
{
"id": "DocumentReference.relatesTo.target",
"path": "DocumentReference.relatesTo.target",
"short": "Target of the relationship",
"definition": "The target document of this relationship.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/DocumentReference"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id"
},
{
"identity": "xds",
"map": "DocumentEntry Associations reference"
}
]
},
{
"id": "DocumentReference.description",
"path": "DocumentReference.description",
"short": "Human-readable description (title)",
"definition": "Human-readable description of the source document. This is sometimes known as the \"title\".",
"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"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-25"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text"
},
{
"identity": "xds",
"map": "DocumentEntry.description"
}
]
},
{
"id": "DocumentReference.securityLabel",
"path": "DocumentReference.securityLabel",
"short": "Document security-tags",
"definition": "A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the \"reference\" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.",
"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. 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": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "extensible",
"description": "Security Labels from the Healthcare Privacy and Security Classification System.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/security-labels"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-18"
},
{
"identity": "rim",
"map": ".confidentialityCode"
},
{
"identity": "xds",
"map": "DocumentEntry.confidentialityCode"
}
]
},
{
"id": "DocumentReference.content",
"path": "DocumentReference.content",
"short": "Document referenced",
"definition": "The document and format referenced. There may be multiple content element repetitions, each with a different format.",
"min": 1,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "document.text"
}
]
},
{
"id": "DocumentReference.content.attachment",
"path": "DocumentReference.content.attachment",
"short": "Where to access the document",
"definition": "The document or url of the document along with critical metadata to prove content has integrity.",
"min": 1,
"max": "1",
"type": [
{
"code": "Attachment"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "TXA-3 for mime type"
},
{
"identity": "rim",
"map": "document.text"
},
{
"identity": "xds",
"map": "DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title"
}
]
},
{
"id": "DocumentReference.content.format",
"path": "DocumentReference.content.format",
"short": "Format/content rules for the document",
"definition": "An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.",
"comments": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.",
"min": 0,
"max": "*",
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Document Format Codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/formatcodes"
}
},
"mapping": [
{
"identity": "rim",
"map": "document.text"
},
{
"identity": "xds",
"map": "DocumentEntry.formatCode"
}
]
},
{
"id": "DocumentReference.context",
"path": "DocumentReference.context",
"short": "Clinical context of document",
"definition": "The clinical context in which the document was prepared.",
"comments": "These values are primarily added to help with searching for interesting/relevant documents.",
"min": 0,
"max": "1",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']"
}
]
},
{
"id": "DocumentReference.context.encounter",
"path": "DocumentReference.context.encounter",
"short": "Context of the document content",
"definition": "Describes the clinical encounter or type of care that the document content is associated with.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Encounter"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"id": "DocumentReference.context.event",
"path": "DocumentReference.context.event",
"short": "Main Clinical Acts Documented",
"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 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": 0,
"max": "*",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "This list of codes represents the main clinical acts being documented.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActCode"
}
},
"mapping": [
{
"identity": "rim",
"map": ".code"
},
{
"identity": "xds",
"map": "DocumentEntry.eventCodeList"
}
]
},
{
"id": "DocumentReference.context.period",
"path": "DocumentReference.context.period",
"short": "Time of service that is being documented",
"definition": "The time period over which the service that is described by the document was provided.",
"min": 0,
"max": "1",
"type": [
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".effectiveTime"
},
{
"identity": "xds",
"map": "DocumentEntry.serviceStartTime DocumentEntry.serviceStopTime"
}
]
},
{
"id": "DocumentReference.context.facilityType",
"path": "DocumentReference.context.facilityType",
"short": "Kind of facility where patient was seen",
"definition": "The kind of facility where the patient was seen.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "XDS Facility Type.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-facilitycodes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.healthcareFacilityTypeCode"
}
]
},
{
"id": "DocumentReference.context.practiceSetting",
"path": "DocumentReference.context.practiceSetting",
"short": "Additional details about where the content was created (e.g. clinical specialty)",
"definition": "This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.",
"comments": "The value set for this content has an example binding because it is a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR and XDM for Direct Messaging Specification, Version 1), as well as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * XDS Connect-a-thon practiceSettingCode.",
"requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.",
"min": 0,
"max": "1",
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Additional details about where the content was created (e.g. clinical specialty).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-practice-codes"
}
},
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
},
{
"identity": "xds",
"map": "DocumentEntry.practiceSettingCode"
}
]
},
{
"id": "DocumentReference.context.sourcePatientInfo",
"path": "DocumentReference.context.sourcePatientInfo",
"short": "Patient demographics from source",
"definition": "The Patient Information as known when the document was published. May be a reference to a version specific, or contained.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Patient"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
},
{
"identity": "xds",
"map": "DocumentEntry.sourcePatientInfo DocumentEntry.sourcePatientId"
}
]
},
{
"id": "DocumentReference.context.related",
"path": "DocumentReference.context.related",
"short": "Related identifiers or resources",
"definition": "Related identifiers or resources associated with the DocumentReference.",
"comments": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.",
"min": 0,
"max": "*",
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]"
},
{
"identity": "xds",
"map": "DocumentEntry.referenceIdList"
}
]
},
{
"id": "DocumentReference.context.related.identifier",
"path": "DocumentReference.context.related.identifier",
"short": "Identifier of related objects or events",
"definition": "Related identifier to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order numbers, accession numbers, XDW workflow numbers.",
"min": 0,
"max": "1",
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct] .id"
}
]
},
{
"id": "DocumentReference.context.related.ref",
"path": "DocumentReference.context.related.ref",
"short": "Related Resource",
"definition": "Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order, DiagnosticRequest, Procedure, EligibilityRequest, etc.",
"min": 0,
"max": "1",
"type": [
{
"code": "Reference",
"profile": "http://hl7.org/fhir/StructureDefinition/Resource"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct].text.reference"
}
]
}
]
}
}
Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.
© HL7.org 2011+. FHIR STU3 Ballot (v1.6.0-9663) generated on Thu, Aug 11, 2016 17:06+1000. QA Page
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