This page is part of the FHIR Specification (v3.5.0: R4 Ballot #2). 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
| DocumentReference | when describing a CDA |
| masterIdentifier | ClinicalDocument/id |
| identifier | |
| status | |
| docStatus | |
| type | ClinicalDocument/code/@code
The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted. |
| category | Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code |
| subject | ClinicalDocument/recordTarget/ |
| date | ClinicalDocument/effectiveTime |
| agent | ClinicalDocument/author |
| type | |
| who | |
| authenticator | ClinicalDocument/legalAuthenticator |
| custodian | |
| relatesTo | |
| code | |
| target | |
| description | |
| securityLabel | ClinicalDocument/confidentialityCode/@code |
| content | |
| attachment | ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/efectiveTime |
| format | derived from the IHE Profile or Implementation Guide templateID |
| context | |
| encounter | |
| event | |
| period | ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value |
| facilityType | usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code |
| practiceSetting | usually from a mapping to a local ValueSet |
| sourcePatientInfo | ClinicalDocument/recordTarget/ |
| related | ClinicalDocument/relatedDocument |
| DocumentReference | Document[classCode="DOC" and moodCode="EVN"] |
| masterIdentifier | .id |
| identifier | .id / .setId |
| status | interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete" |
| docStatus | .statusCode |
| type | ./code |
| category | .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code |
| subject | .participation[typeCode="SBJ"].role[typeCode="PAT"] |
| date | .availabilityTime[type="TS"] |
| agent | .participation |
| type | .participation.typeCode |
| who | .participation[typeCode="AUT"].role[classCode="ASSIGNED"] |
| authenticator | .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"] |
| custodian | .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"] |
| relatesTo | .outboundRelationship |
| code | .outboundRelationship.typeCode |
| target | .target[classCode="DOC", moodCode="EVN"].id |
| description | .outboundRelationship[typeCode="SUBJ"].target.text |
| securityLabel | .confidentialityCode |
| content | document.text |
| attachment | document.text |
| format | document.text |
| context | outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT'] |
| encounter | unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct]) |
| event | .code |
| period | .effectiveTime |
| facilityType | .participation[typeCode="LOC"].role[classCode="DSDLOC"].code |
| practiceSetting | .participation[typeCode="LOC"].role[classCode="DSDLOC"].code |
| sourcePatientInfo | .participation[typeCode="SBJ"].role[typeCode="PAT"] |
| related | ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] |
| DocumentReference | |
| masterIdentifier | DocumentEntry.uniqueId |
| identifier | DocumentEntry.entryUUID |
| status | DocumentEntry.availabilityStatus |
| docStatus | |
| type | DocumentEntry.type |
| category | DocumentEntry.class |
| subject | DocumentEntry.patientId |
| date | DocumentEntry.creationTime |
| agent | DocumentEntry.author |
| type | |
| who | |
| authenticator | DocumentEntry.legalAuthenticator |
| custodian | |
| relatesTo | DocumentEntry Associations |
| code | DocumentEntry Associations type |
| target | DocumentEntry Associations reference |
| description | DocumentEntry.comments |
| securityLabel | DocumentEntry.confidentialityCode |
| content | |
| attachment | DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title |
| format | DocumentEntry.formatCode |
| context | |
| encounter | |
| event | DocumentEntry.eventCodeList |
| period | DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime |
| facilityType | DocumentEntry.healthcareFacilityTypeCode |
| practiceSetting | DocumentEntry.practiceSettingCode |
| sourcePatientInfo | DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId |
| related | DocumentEntry.referenceIdList |
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