Release 5 Preview #3

This page is part of the FHIR Specification (v4.5.0: R5 Preview #3). 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

10.2.9 Resource DocumentReference - Mappings

Orders and Observations Work GroupMaturity Level: N/AStandards Status: InformativeSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

Mappings:

FiveWs Pattern Mapping

Workflow Pattern

HL7 v2 Mapping

CDA (R2)

RIM Mapping

XDS metadata equivalent

FHIR Composition

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

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

DocumentReference
    identifierFiveWs.identifier
    statusFiveWs.status
    docStatusFiveWs.status
    typeFiveWs.what[x]
    categoryFiveWs.what[x]
    subjectFiveWs.subject[x]
    encounterFiveWs.context
    dateFiveWs.recorded
        partyFiveWs.witness
        identifierFiveWs.identifier

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

DocumentReferenceEvent
    identifierEvent.identifier
    statusEvent.status
    typeEvent.code
    subjectEvent.subject
    encounterEvent.context
    dateEvent.occurrence[x]
    authorEvent.performer.actor
    attesterEvent.performer.actor
    custodianEvent.performer.actor
        identifierEvent.identifier

10.2.9.3 HL7 v2 Mapping (http://hl7.org/v2 )

DocumentReference
    identifierTXA-16?
    basedOn
    statusTXA-19
    docStatusTXA-17
    typeTXA-2
    category
    subjectPID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
    encounter
    event
    facilityType
    practiceSetting
    period
    date
    authorTXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    attester
        mode
        time
        partyTXA-10
    custodian
    relatesTo
        code
        target
    descriptionTXA-25
    securityLabelTXA-18
    content
        attachmentTXA-3 for mime type
        format
        identifierTXA-12
    sourcePatientInfo
    related

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

DocumentReferencewhen describing a CDA
    identifier
    basedOn
    status
    docStatus
    typeClinicalDocument/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.
    categoryDerived 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
    subjectClinicalDocument/recordTarget/
    encounter
    event
    facilityTypeusually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
    practiceSettingusually from a mapping to a local ValueSet
    periodClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
    date
    authorClinicalDocument/author
    attester.authenticator/.legalAuthenticator
        modeimplied by .authenticator/.legalAuthenticator
        time.authenticator.time
        party.authenticator.assignedEnttty
    custodian
    relatesTo
        code
        target
    description
    securityLabelClinicalDocument/confidentialityCode/@code
    content
        attachmentClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        formatderived from the IHE Profile or Implementation Guide templateID
        identifierClinicalDocument/id
    sourcePatientInfoClinicalDocument/recordTarget/
    relatedClinicalDocument/relatedDocument

10.2.9.5 RIM Mapping (http://hl7.org/v3 )

DocumentReferenceDocument[classCode="DOC" and moodCode="EVN"]
    identifier.id / .setId
    basedOn.outboundRelationship[typeCode=FLFS].target
    statusinterim: .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"]
    encounterunique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
    event.code
    facilityType.participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    practiceSetting.participation[typeCode="LOC"].role[classCode="DSDLOC"].code
    period.effectiveTime
    date.availabilityTime[type="TS"]
    author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    attester.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
        modeunique(./modeCode)
        time./time[type="TS" and isNormalDatatype()]
        party./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
    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
    contentdocument.text
        attachmentdocument.text
        formatdocument.text
        identifier.id
    sourcePatientInfo.participation[typeCode="SBJ"].role[typeCode="PAT"]
    related./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]

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

DocumentReference
    identifierDocumentEntry.entryUUID
    basedOnDocumentEntry.referenceIdList
    statusDocumentEntry.availabilityStatus
    docStatus
    typeDocumentEntry.typeCode
    categoryDocumentEntry.classCode
    subjectDocumentEntry.patientId
    encounter
    eventDocumentEntry.eventCodeList
    facilityTypeDocumentEntry.healthcareFacilityTypeCode
    practiceSettingDocumentEntry.practiceSettingCode
    periodDocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
    date
    authorDocumentEntry.author
    attesterDocumentEntry.legalAuthenticator
        mode
        time
        party
    custodian
    relatesToDocumentEntry Associations
        codeDocumentEntry Associations type
        targetDocumentEntry Associations reference
    descriptionDocumentEntry.comments
    securityLabelDocumentEntry.confidentialityCode
    content
        attachmentDocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        formatDocumentEntry.formatCode
        identifierDocumentEntry.uniqueId
    sourcePatientInfoDocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
    relatedDocumentEntry.referenceIdList

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

DocumentReferencewhen describing a Composition
    identifier
    basedOn
    status
    docStatusComposition.status
    typeComposition.type
    categoryComposition.class
    subjectComposition.subject
    encounterComposition.encounter
    eventComposition.event.code
    facilityTypeusually from a mapping to a local ValueSet
    practiceSettingusually from a mapping to a local ValueSet
    periodComposition.event.period
    dateComposition.date
    authorComposition.author
    attesterComposition.attester
        modeComposition.attester.mode
        timeComposition.attester.time
        partyComposition.attester.party
    custodianComposition.custodian
    relatesToComposition.relatesTo
        codeComposition.relatesTo.code
        targetComposition.relatesTo.target
    description
    securityLabelComposition.confidentiality, Composition.meta.security
    contentBundle(Composition+*)
        attachmentComposition.language,
Composition.title,
Composition.date
        formatComposition.meta.profile
        identifierComposition.identifier
    sourcePatientInfoComposition.subject
    relatedComposition.event.detail