Release 5

This page is part of the FHIR Specification (v5.0.0: R5 - STU). This is the current published version. For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4 R3 R2

2.8.15.2.4 StructureDefinition: ClinicalDocument - Mappings

Structured Documents icon 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).

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

ClinicalDocument
CompositionEvent
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   modifierExtension
   url
   identifierEvent.identifier
   version
   statusEvent.status
   typeEvent.code
   category
   subjectEvent.subject
   encounterEvent.encounter
   dateEvent.occurrence[x]
   useContext
   authorEvent.performer
   name
   title
   note
   attester
      id
      extension
      modifierExtension
      mode
      time
      party
   custodian
   relatesTo
   event
      id
      extension
      modifierExtension
      period
      detail
   section
      id
      extension
      modifierExtension
      title
      code
      author
      focus
      text
      orderedBy
      entry
      emptyReason
      section

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

ClinicalDocument
CompositionEntity, Role, or Act,Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
   id
   meta
   implicitRules
   language
   textAct.text?
   containedN/A
   extensionN/A
   modifierExtensionN/A
   url
   identifierDocument.id / Document.setId
   version
   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and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"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"]
   useContext
   author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
   name
   title./title
   note
   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
   eventoutboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
      idn/a
      extensionn/a
      modifierExtensionN/A
      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
      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]

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

ClinicalDocument
CompositionClinicalDocument
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   modifierExtension
   url
   identifier.setId
   version.versionNumber
   statusn/a
   type.code
   categoryn/a
   subject.recordTarget
   encounter.componentOf.encompassingEncounter
   date.effectiveTime
   useContext
   author.author.assignedAuthor
   name
   title.title
   note
   attester.authenticator/.legalAuthenticator
      id
      extension
      modifierExtension
      modeimplied by .authenticator/.legalAuthenticator
      time.authenticator.time
      party.authenticator.assignedEnttty
   custodian.custodian.assignedCustodian
   relatesTo.relatedDocument
   event.documentationOf.serviceEvent
      id
      extension
      modifierExtension
      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
      orderedByn/a
      entry.entry
      emptyReasonn/a
      section.component.section

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

ClinicalDocument
Compositionwhen described by DocumentReference
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   modifierExtension
   url
   identifierDocumentReference.identifier
   versionDocumentReference.version
   statusDocumentReference.docStatus
   typeDocumentReference.type
   categoryDocumenttReference.category
   subjectDocumentReference.subject
   encounterDocumentReference.context
   dateDocumentReference.content.attachment.date, DocumentReference.date
   useContext
   authorDocumentReference.author
   name
   titleDocumentReference.description, DocumentReference.content.attachment.title
   note
   attesterDocumentReference.attester
      id
      extension
      modifierExtension
      modeDocumentReference.attester.mode
      timeDocumentReference.attester.time
      partyDocumentReference.attester.party
   custodianDocumentReference.custodian
   relatesToDocumentReference.relatesTo
   event
      id
      extension
      modifierExtension
      periodDocumentReference.period
      detailDocumentReference.event
   section
      id
      extension
      modifierExtension
      title
      code
      author
      focus
      text
      orderedBy
      entry
      emptyReason
      section

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

ClinicalDocument
Compositioninfrastructure.documents
   id
   meta
   implicitRules
   language
   text
   contained
   extension
   modifierExtension
   urlFiveWs.identifier
   identifierFiveWs.identifier
   versionFiveWs.version
   statusFiveWs.status
   typeFiveWs.class
   categoryFiveWs.class
   subjectFiveWs.subject[x]
   encounterFiveWs.context
   dateFiveWs.done[x]
   useContext
   authorFiveWs.author
   name
   title
   note
   attester
      id
      extension
      modifierExtension
      mode
      time
      partyFiveWs.witness
   custodian
   relatesTo
   event
      id
      extension
      modifierExtension
      period
      detail
   section
      id
      extension
      modifierExtension
      title
      code
      authorFiveWs.author
      focus
      text
      orderedBy
      entry
      emptyReason
      section