Release 4

This page is part of the FHIR Specification (v4.0.1: R4 - Mixed Normative and STU) in it's permanent home (it will always be available at this URL). 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

Structured Documents Work GroupMaturity Level: N/AStandards Status: InformativeSecurity Category: Not Classified Compartments: Device, Encounter, Patient, Practitioner, RelatedPerson

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

DocumentReference
    masterIdentifierFiveWs.identifier
    identifierFiveWs.identifier
    statusFiveWs.status
    docStatusFiveWs.status
    typeFiveWs.class
    categoryFiveWs.class
    subjectFiveWs.subject[x]
    dateFiveWs.recorded
    authenticatorFiveWs.witness
        encounterFiveWs.context
DocumentReferenceEvent
    masterIdentifierEvent.identifier
    identifierEvent.identifier
    statusEvent.status
    typeEvent.code
    subjectEvent.subject
    dateEvent.occurrence[x]
    authorEvent.performer.actor
    authenticatorEvent.performer.actor
    custodianEvent.performer.actor
        encounterEvent.context
DocumentReference
    masterIdentifierTXA-12
    identifierTXA-16?
    statusTXA-19
    docStatusTXA-17
    typeTXA-2
    category
    subjectPID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
    date
    authorTXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    authenticatorTXA-10
    custodian
    relatesTo
        code
        target
    descriptionTXA-25
    securityLabelTXA-18
    content
        attachmentTXA-3 for mime type
        format
    context
        encounter
        event
        period
        facilityType
        practiceSetting
        sourcePatientInfo
        related
DocumentReferencewhen describing a CDA
    masterIdentifierClinicalDocument/id
    identifier
    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/
    date
    authorClinicalDocument/author
    authenticatorClinicalDocument/legalAuthenticator
    custodian
    relatesTo
        code
        target
    description
    securityLabelClinicalDocument/confidentialityCode/@code
    content
        attachmentClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        formatderived from the IHE Profile or Implementation Guide templateID
    context
        encounter
        event
        periodClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
        facilityTypeusually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
        practiceSettingusually from a mapping to a local ValueSet
        sourcePatientInfoClinicalDocument/recordTarget/
        relatedClinicalDocument/relatedDocument
DocumentReferenceDocument[classCode="DOC" and moodCode="EVN"]
    masterIdentifier.id
    identifier.id / .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("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"]
    author.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
    contentdocument.text
        attachmentdocument.text
        formatdocument.text
    contextoutboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
        encounterunique(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
    masterIdentifierDocumentEntry.uniqueId
    identifierDocumentEntry.entryUUID
    statusDocumentEntry.availabilityStatus
    docStatus
    typeDocumentEntry.type
    categoryDocumentEntry.class
    subjectDocumentEntry.patientId
    date
    authorDocumentEntry.author
    authenticatorDocumentEntry.legalAuthenticator
    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
    context
        encounter
        eventDocumentEntry.eventCodeList
        periodDocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
        facilityTypeDocumentEntry.healthcareFacilityTypeCode
        practiceSettingDocumentEntry.practiceSettingCode
        sourcePatientInfoDocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
        relatedDocumentEntry.referenceIdList
DocumentReferencewhen describing a Composition
    masterIdentifierComposition.identifier
    identifier
    status
    docStatusComposition.status
    typeComposition.type
    categoryComposition.class
    subjectComposition.subject
    dateComposition.date
    authorComposition.author
    authenticatorComposition.attester
    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
    context
        encounterComposition.encounter
        eventComposition.event.code
        periodComposition.event.period
        facilityTypeusually from a mapping to a local ValueSet
        practiceSettingusually from a mapping to a local ValueSet
        sourcePatientInfoComposition.subject
        relatedComposition.event.detail