Release 4B Snapshot #1

This page is part of the FHIR Specification v4.3.0-snapshot1: R4B Snapshot to support the Jan 2022 Connectathon. About the R4B version of FHIR. The current officially released version is 4.3.0. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.41.15.2.4 StructureDefinition: Clinical Document - Mappings

Structured Documents Work Group Maturity Level: 0Trial Use Use Context: Any

Mappings:

Workflow Pattern

RIM Mapping

CDA (R2)

FHIR DocumentReference

FiveWs Pattern Mapping

Mappings for the clinicaldocument Profile (see Mappings to Other Standards for further information & status).

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

Clinical Document
CompositionEvent
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   extensionversionNumber
   modifierExtension
   identifierEvent.identifier
   statusEvent.status
   typeEvent.code
   categoryEvent.subject
   subject
   encounterEvent.context
   dateEvent.occurrence[x]
   authorEvent.performer
   title
   confidentiality
   attester
      id
      extension
      modifierExtension
      mode
      time
      party
   custodian
   relatesTo
      id
      extension
      modifierExtension
      code
      target[x]
   event
      id
      extension
      modifierExtension
      code
      period
      detail
   section
      id
      extension
      modifierExtension
      title
      code
      author
      focus
      text
      mode
      orderedBy
      entry
      emptyReason
      section

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

Clinical Document
CompositionEntity. Role, or Act
   id
   meta
   implicitRules
   language
   textAct.text?
   containedN/A
   extension
   extensionversionNumber
   modifierExtensionN/A
   identifierDocument.id / Document.setId
   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("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
   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])
   date.effectiveTime[type="TS"]
   author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
   title./title
   confidentiality.confidentialityCode
   attester.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
      idn/a
      extensionn/a
      modifierExtensionN/A
      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
      idn/a
      extensionn/a
      modifierExtensionN/A
      code.outboundRelationship.typeCode
      target[x].target[classCode="DOC", moodCode="EVN"].id
   eventoutboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
      idn/a
      extensionn/a
      modifierExtensionN/A
      code.code
      period.effectiveTime
      detail.outboundRelationship[typeCode="SUBJ"].target
   section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      code./code
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      focus
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedBy.outboundRelationship[typeCode=COMP].sequenceNumber > 1
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReason.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]

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

Clinical Document
CompositionClinicalDocument
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   extensionversionNumber
   modifierExtension
   identifier.setId
   statusn/a
   type.code
   categoryn/a
   subject.recordTarget
   encounter.componentOf.encompassingEncounter
   date.effectiveTime
   author.author.assignedAuthor
   title.title
   confidentiality.confidentialityCode
   attester.authenticator/.legalAuthenticator
      id
      extension
      modifierExtension
      modeimplied by .authenticator/.legalAuthenticator
      time.authenticator.time
      party.authenticator.assignedEnttty
   custodian.custodian.assignedCustodian
   relatesTo.relatedDocument
      id
      extension
      modifierExtension
      code.relatedDocument.typeCode
      target[x].relatedDocument.id
   event.documentationOf.serviceEvent
      id
      extension
      modifierExtension
      code.code
      period.effectiveTime
      detailn/a
   section.component.structuredBody.component.section
      id
      extension
      modifierExtension
      title.title
      code.code
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      orderedByn/a
      entry.entry
      emptyReasonn/a
      section.component.section

2.41.15.6 FHIR DocumentReference (http://hl7.org/fhir/documentreference)

Clinical Document
Compositionwhen described by DocumentReference
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   extensionversionNumber
   modifierExtension
   identifierDocumentReference.masterIdentifier
   statusDocumentReference.status
   typeDocumentReference.type
   categoryDocumenttReference.category
   subjectDocumentReference.subject
   encounterDocumentReference.context.encounter
   dateDocumentReference.content.attachment.date, DocumentReference.created
   authorDocumentReference.agent
   titleDocumentReference.description, DocumentReference.content.attachment.title
   confidentialityDocumentReference.securityLabel
   attesterDocumentReference.authenticator
      id
      extension
      modifierExtension
      mode
      time
      party
   custodianDocumentReference.custodian
   relatesToDocumentReference.relatesTo
      id
      extension
      modifierExtension
      codeDocumentReference.relatesTo.code
      target[x]DocumentReference.relatesTo.target
   eventDocumentReference.event
      id
      extension
      modifierExtension
      codeDocumentReference.event.code
      periodDocumentReference.event.period
      detail
   section
      id
      extension
      modifierExtension
      title
      code
      author
      focus
      text
      mode
      orderedBy
      entry
      emptyReason
      section

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

Clinical Document
Compositioninfrastructure.documents
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   extensionversionNumber
   modifierExtension
   identifierFiveWs.identifier
   statusFiveWs.status
   typeFiveWs.class
   categoryFiveWs.class
   subjectFiveWs.subject[x]
   encounterFiveWs.context
   dateFiveWs.done[x]
   authorFiveWs.author
   title
   confidentiality
   attester
      id
      extension
      modifierExtension
      mode
      time
      partyFiveWs.witness
   custodian
   relatesTo
      id
      extension
      modifierExtension
      code
      target[x]
   event
      id
      extension
      modifierExtension
      code
      period
      detail
   section
      id
      extension
      modifierExtension
      title
      code
      authorFiveWs.author
      focus
      text
      modeFiveWs.class
      orderedBy
      entry
      emptyReason
      section