DSTU2
This page is part of the FHIR Specification (v1.0.2: DSTU 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 
StructureDefinition for XDSDocumentEntry
{
"resourceType": "StructureDefinition",
"id": "xdsdocumentreference",
"text": {
"status": "generated",
"div": "<div>!-- Snipped for Brevity --></div>"
},
"url": "http://hl7.org/fhir/StructureDefinition/xdsdocumentreference",
"name": "XDS profile for Document Reference",
"status": "draft",
"publisher": "HL7",
"contact": [
{
"telecom": [
{
"system": "other",
"value": "http://www.hl7.org"
}
]
}
],
"date": "2012-06-24",
"description": "XDSDocumentEntry",
"fhirVersion": "1.0.2",
"kind": "resource",
"constrainedType": "DocumentReference",
"abstract": false,
"base": "http://hl7.org/fhir/StructureDefinition/DocumentReference",
"snapshot": {
"element": [
{
"path": "DocumentReference",
"name": "XDSDocumentReference",
"short": "XDSDocumentEntry",
"definition": "A reference to a document.",
"comments": "Usually, this is used for documents other than those defined by FHIR.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference",
"min": 0,
"max": "*"
},
"type": [
{
"code": "DocumentReference"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]"
},
{
"identity": "w5",
"map": "infrastructure.documents"
}
]
},
{
"path": "DocumentReference.id",
"short": "Logical id of this artifact",
"definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.",
"comments": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Bundles always have an id, though it is usually a generated UUID.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"isSummary": true
},
{
"path": "DocumentReference.meta",
"short": "Metadata about the resource",
"definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content may not always be associated with version changes to the resource.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.meta",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Meta"
}
],
"isSummary": true
},
{
"path": "DocumentReference.implicitRules",
"short": "A set of rules under which this content was created",
"definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content.",
"comments": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element as much as possible.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.implicitRules",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"isModifier": true,
"isSummary": true
},
{
"path": "DocumentReference.language",
"short": "Language of the resource content",
"definition": "The base language in which the resource is written.",
"comments": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"binding": {
"strength": "required",
"description": "A human language.",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
}
},
{
"path": "DocumentReference.text",
"short": "Text summary of the resource, for human interpretation",
"definition": "A human-readable narrative that contains a summary of the resource, and may be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.",
"comments": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative.",
"alias": [
"narrative",
"html",
"xhtml",
"display"
],
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.text",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Narrative"
}
],
"condition": [
"dom-1"
],
"mapping": [
{
"identity": "rim",
"map": "Act.text?"
}
]
},
{
"path": "DocumentReference.contained",
"short": "Contained, inline Resources",
"definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.",
"comments": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.",
"alias": [
"inline resources",
"anonymous resources",
"contained resources"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.contained",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Resource"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the resource, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.masterIdentifier",
"short": "XDSDocumentEntry.uniqueId",
"definition": "Globally unique identifier assigned to the document by the creating entity. A DocumentEntry representing a single document is identified by the uniqueId attribute; the linkage between DocumentEntry and the Document it represents is made with the uniqueId attribute. This unique identifier may be used in other documents to reference this document.",
"comments": "CDA Document Id extension and root.",
"requirements": "The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64 character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form \"oid^extension\", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.masterIdentifier",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.uniqueId"
},
{
"identity": "v2",
"map": "TXA-12"
},
{
"identity": "rim",
"map": ".id"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"path": "DocumentReference.identifier",
"short": "XDSDocumentEntry.referenceIdList",
"definition": "Other identifiers for the document.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.identifier",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.entryUUID"
},
{
"identity": "v2",
"map": "TXA-16?"
},
{
"identity": "rim",
"map": ".id / .setId"
},
{
"identity": "w5",
"map": "id"
}
]
},
{
"path": "DocumentReference.subject",
"short": "XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo",
"definition": "The patientId represents the subject of care of the document. The value of the patientId shall be the same for all new documents of a SubmissionSet. Patient information typically includes: the patient first and last name, sex, and birth date.",
"comments": "In the context of XDS, the patientId shall be the one with use = official. The Clinical XDS Affinity Domain policies may require more or less specific information and format. This patient information is not intended to be updated once the Document is registered (just as the Document content and metadata itself will not be updated without replacing the previous document). As sourcePatientInfo may have been updated by the source actor, it may no longer be in use within the Document Source (EHR-CR). It is only intended as an audit/checking mechanism and has occasional use for Document Consumer actors.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.subject",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.patientId"
},
{
"identity": "v2",
"map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
},
{
"identity": "w5",
"map": "who.focus"
}
]
},
{
"path": "DocumentReference.type",
"short": "XDSDocumentEntry.typeCode",
"definition": "The code specifying the particular kind of document (e.g. Prescription, Discharge Summary, Report). It is suggested that the XDS Affinity Domain draws these values from a coding scheme providing a coarse level of granularity (about 10 to 100 entries). Shall have a single value.",
"comments": "Key metadata element describing the document, used in searching/filtering.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.type",
"min": 1,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Precise type of clinical document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.type"
},
{
"identity": "v2",
"map": "TXA-2"
},
{
"identity": "rim",
"map": "./code"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "DocumentReference.class",
"short": "XDSDocumentEntry.classCode",
"definition": "A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type.",
"comments": "XDSDocumentEntry.typeCode.",
"requirements": "Helps humans to assess whether the document is of interest when viewing a list of documents.",
"alias": [
"kind"
],
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.class",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "High-level kind of a clinical document at a macro level.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-doc-classcodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.class"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code"
},
{
"identity": "w5",
"map": "class"
}
]
},
{
"path": "DocumentReference.author",
"short": "XDSDocumentEntry.author",
"definition": "Represents the humans and/or machines that authored the document.",
"comments": "Not necessarily who did the actual data entry (i.e. typist) it in or who was the source (informant).",
"min": 1,
"max": "*",
"base": {
"path": "DocumentReference.author",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.author"
},
{
"identity": "v2",
"map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "w5",
"map": "who.author"
}
]
},
{
"path": "DocumentReference.custodian",
"short": "n/a",
"definition": "Org which maintains the document.",
"comments": "Identifies the logical organization to go to find the current version, where to report issues, etc. This is different from the physical location of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.",
"min": 0,
"max": "0",
"base": {
"path": "DocumentReference.custodian",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Organization"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]"
}
]
},
{
"path": "DocumentReference.authenticator",
"short": "??",
"definition": "Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator.",
"comments": "Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.authenticator",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.legalAuthenticator"
},
{
"identity": "v2",
"map": "TXA-10"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]"
},
{
"identity": "w5",
"map": "who.witness"
}
]
},
{
"path": "DocumentReference.created",
"short": "XDSDocumentEntry.creationTime",
"definition": "Represents the time the author created the document in the Document Source.",
"comments": "Creation time is used for tracking, organizing versions and searching. This is the creation time of the document, not the source material on which it is based.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.created",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "v2",
"map": "TXA-6"
},
{
"identity": "rim",
"map": ".effectiveTime[type=\"TS\"]"
},
{
"identity": "w5",
"map": "when.done"
}
]
},
{
"path": "DocumentReference.indexed",
"short": "XDS submission time or XDSDocumentEntry.creationTime if unknown",
"definition": "When this document reference created.",
"comments": "Referencing/indexing time is used for tracking, organizing versions and searching.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.indexed",
"min": 1,
"max": "1"
},
"type": [
{
"code": "instant"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.submissionTime"
},
{
"identity": "rim",
"map": ".availabilityTime[type=\"TS\"]"
},
{
"identity": "w5",
"map": "when.recorded"
}
]
},
{
"path": "DocumentReference.status",
"short": "implied by XDS workflow",
"definition": "This attribute is always set to Approved as part of the submission of new XDS Documents. It may be changed to Deprecated under the primary responsibility of the Document Source with possible patient supervision. Although XDS supports the ability to delete documents, there is no such state as ???the Document Entry is removed??? (only an audit trail is kept if such a deletion is allowed).",
"comments": "This is the status of the DocumentReference object, which might be independent from the docStatus element.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.status",
"min": 1,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isModifier": true,
"isSummary": true,
"binding": {
"strength": "required",
"description": "The status of the document reference.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-reference-status"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry status"
},
{
"identity": "v2",
"map": "TXA-19"
},
{
"identity": "rim",
"map": "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\""
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "DocumentReference.docStatus",
"short": "preliminary | final | appended | amended | entered-in-error",
"definition": "Status of the underlying document.",
"comments": "The document that is pointed to might be in various lifecycle states.",
"min": 0,
"max": "0",
"base": {
"path": "DocumentReference.docStatus",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "Status of the underlying document.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/composition-status"
}
},
"mapping": [
{
"identity": "v2",
"map": "TXA-17"
},
{
"identity": "rim",
"map": ".statusCode"
},
{
"identity": "w5",
"map": "status"
}
]
},
{
"path": "DocumentReference.relatesTo",
"short": "Relationships that this document has with other document references that already exist",
"definition": "Relationships to other documents.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.relatesTo",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"isModifier": true,
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".outboundRelationship"
}
]
},
{
"path": "DocumentReference.relatesTo.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.relatesTo.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.relatesTo.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.relatesTo.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.relatesTo.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.relatesTo.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.relatesTo.code",
"short": "The type of relationship that this document has with anther document",
"definition": "supersedes | transforms | signs | appends.",
"comments": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.relatesTo.code",
"min": 1,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"isSummary": true,
"binding": {
"strength": "required",
"description": "The type of relationship between documents.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/document-relationship-type"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry Associations type"
},
{
"identity": "rim",
"map": ".outboundRelationship.typeCode"
}
]
},
{
"path": "DocumentReference.relatesTo.target",
"short": "The target document of this relationship",
"definition": "Target of the relationship.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.relatesTo.target",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/DocumentReference"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry Associations reference"
},
{
"identity": "rim",
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id"
}
]
},
{
"path": "DocumentReference.description",
"short": "XDSDocumentEntry.title",
"definition": "Represents the title of the document.",
"comments": "What the document is about, rather than a terse summary of the document. It is commonly the case that records do not have a title and are collectively referred to by the display name of Record code (e.g. a \"consultation\" or \"progress note\").",
"requirements": "Helps humans to assess whether the document is of interest.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.description",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.description"
},
{
"identity": "v2",
"map": "TXA-25"
},
{
"identity": "rim",
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text"
}
]
},
{
"path": "DocumentReference.securityLabel",
"short": "XDSDocumentEntry.confidentialityCode",
"definition": "The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain.",
"comments": "Enforcement and issues related to highly sensitive documents are beyond the scope of XDS (see security section). confidentialityCode is part of a codification scheme and value set enforced by the Document Registry.",
"requirements": "Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.securityLabel",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "extensible",
"description": "Security Labels from the Healthcare Privacy and Security Classification System.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/security-labels"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.confidentialityCode"
},
{
"identity": "v2",
"map": "TXA-18"
},
{
"identity": "rim",
"map": ".confidentialityCode"
}
]
},
{
"path": "DocumentReference.content",
"short": "Document referenced",
"definition": "The document and format referenced. There may be multiple content element repetitions, each with a different format.",
"min": 1,
"max": "*",
"base": {
"path": "DocumentReference.content",
"min": 1,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "document.text"
}
]
},
{
"path": "DocumentReference.content.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.content.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.content.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.content.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.content.attachment",
"short": "Where to access the document",
"definition": "The document or url of the document along with critical metadata to prove content has integrity.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.content.attachment",
"min": 1,
"max": "1"
},
"type": [
{
"code": "Attachment"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title"
},
{
"identity": "v2",
"map": "TXA-3 for mime type"
},
{
"identity": "rim",
"map": "document.text"
}
]
},
{
"path": "DocumentReference.content.attachment.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.attachment.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "Attachment.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.content.attachment.contentType",
"short": "XDSDocumentEntry.mimeType",
"definition": "MIME type of the document in the Repository.",
"requirements": "Processors of the data need to be able to know how to interpret the data.",
"min": 1,
"max": "1",
"base": {
"path": "Attachment.contentType",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"exampleCode": "text/plain; charset=UTF-8, image/png",
"isSummary": true,
"binding": {
"strength": "required",
"description": "The mime type of an attachment. Any valid mime type is allowed.",
"valueSetUri": "http://www.rfc-editor.org/bcp/bcp13.txt"
},
"mapping": [
{
"identity": "v2",
"map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used"
},
{
"identity": "rim",
"map": "./mediaType, ./charset"
}
]
},
{
"path": "DocumentReference.content.attachment.language",
"short": "XDSDocumentEntry.languageCode",
"definition": "Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066.",
"comments": "This value may further be restricted by the registry according to XDS Affinity Domain specific policy.",
"requirements": "Users need to be able to choose between the languages in a set of attachments.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.language",
"min": 0,
"max": "1"
},
"type": [
{
"code": "code"
}
],
"exampleCode": "en-AU",
"isSummary": true,
"binding": {
"strength": "required",
"description": "A human language.",
"valueSetUri": "http://tools.ietf.org/html/bcp47"
},
"mapping": [
{
"identity": "rim",
"map": "./language"
}
]
},
{
"path": "DocumentReference.content.attachment.data",
"short": "Data inline, base64ed",
"definition": "The actual data of the attachment - a sequence of bytes. In XML, represented using base64.",
"comments": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.",
"requirements": "The data needs to able to be transmitted inline.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.data",
"min": 0,
"max": "1"
},
"type": [
{
"code": "base64Binary"
}
],
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "ED.5"
},
{
"identity": "rim",
"map": "./data"
}
]
},
{
"path": "DocumentReference.content.attachment.url",
"short": "repository location (by implication & configuration)",
"definition": "Where to access the document.",
"comments": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.",
"requirements": "The data needs to be transmitted by reference.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.url",
"min": 0,
"max": "1"
},
"type": [
{
"code": "uri"
}
],
"exampleUri": "http://www.acme.com/logo-small.png",
"isSummary": true,
"mapping": [
{
"identity": "v2",
"map": "RP.1+RP.2 - if they refer to a URL (see v2.6)"
},
{
"identity": "rim",
"map": "./reference/literal"
}
]
},
{
"path": "DocumentReference.content.attachment.size",
"short": "XDSDocumentEntry.size",
"definition": "Size in bytes of the byte stream that was provided in the Register and Provide Transaction and stored by the XDS Document Repository. This value is computed by the Document Repository and included in the Register Documents Set Transaction.",
"comments": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.",
"requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.size",
"min": 0,
"max": "1"
},
"type": [
{
"code": "unsignedInt"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A (needs data type R3 proposal)"
}
]
},
{
"path": "DocumentReference.content.attachment.hash",
"short": "XDSDocumentEntry.hash",
"definition": "Hash key of the XDS Document itself.",
"comments": "This value is computed by the Document Repository and used by the Document Registry for detecting the improper resubmission of XDS Documents. If present, shall have a single value. If this attribute is received in a Provide & Register Document Set-b [ITI-41] transaction, it shall be verified by the repository with the actual hash value of the submitted document; an XDSRepositoryMetadataError shall be returned on mismatch.",
"requirements": "Included so that applications can verify that the contents of a location have not changed and so that a signature of the content can implicitly sign the content of an image without having to include the data in the instance or reference the url in the signature.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.hash",
"min": 0,
"max": "1"
},
"type": [
{
"code": "base64Binary"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]"
}
]
},
{
"path": "DocumentReference.content.attachment.title",
"short": "Label to display in place of the data",
"definition": "A label or set of text to display in place of the data.",
"requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.title",
"min": 0,
"max": "1"
},
"type": [
{
"code": "string"
}
],
"exampleString": "Official Corporate Logo",
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./title/data"
}
]
},
{
"path": "DocumentReference.content.attachment.creation",
"short": "Date attachment was first created",
"definition": "The date that the attachment was first created.",
"requirements": "This is often tracked as an integrity issue for use of the attachment.",
"min": 0,
"max": "1",
"base": {
"path": "Attachment.creation",
"min": 0,
"max": "1"
},
"type": [
{
"code": "dateTime"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "N/A (needs data type R3 proposal)"
}
]
},
{
"path": "DocumentReference.content.format",
"short": "Format/content rules for the document",
"definition": "An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.",
"comments": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.content.format",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Coding"
}
],
"isSummary": true,
"binding": {
"strength": "preferred",
"description": "Document Format Codes.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/formatcodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.formatCode"
},
{
"identity": "rim",
"map": "document.text"
}
]
},
{
"path": "DocumentReference.context",
"short": "event codes, service Start & Stop time, and facility type",
"definition": "Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type.",
"comments": "These values are primarily added to help with searching for interesting/relevant documents.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context",
"min": 0,
"max": "1"
},
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']"
}
]
},
{
"path": "DocumentReference.context.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.context.encounter",
"short": "Context of the document content",
"definition": "Describes the clinical encounter or type of care that the document content is associated with.",
"min": 0,
"max": "0",
"base": {
"path": "DocumentReference.context.encounter",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Encounter"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])"
},
{
"identity": "w5",
"map": "context"
}
]
},
{
"path": "DocumentReference.context.event",
"short": "XDSDocumentEntry.eventCodeList",
"definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act.",
"comments": "An event can further specialize the act inherent in the typeCode, such as where it is simply \"Procedure Report\" and the procedure was a \"colonoscopy\". If one or more eventCodes are included, they shall not conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as ???key words??? for certain types of queries.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.event",
"min": 0,
"max": "*"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "This list of codes represents the main clinical acts being documented.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/v3-ActCode"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.eventCodeList"
},
{
"identity": "rim",
"map": ".code"
}
]
},
{
"path": "DocumentReference.context.period",
"short": "XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime",
"definition": "The start and stop time of the service being documented took place.",
"comments": "At least a start date SHALL be provided.",
"min": 1,
"max": "1",
"base": {
"path": "DocumentReference.context.period",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Period"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.serviceStartTime DocumentEntry.serviceStopTime"
},
{
"identity": "rim",
"map": ".effectiveTime"
}
]
},
{
"path": "DocumentReference.context.facilityType",
"short": "XDSDocumentEntry.healthCareFacilityTypeCode",
"definition": "This code represents the type of organizational setting of the clinical encounter during which the documented act occurred.",
"comments": "In some cases, the setting of the encounter is inherent in the typeCode, such as \"Diabetes Clinic Progress Note\". healthcareFacilityTypeCode shall be equivalent to or further specialize the value inherent in the typeCode; for example, where the typeCode is simply \"Clinic Progress Note\" and the value of healthcareFacilityTypeCode is \"private clinic\". The value shall not conflict with the value inherent in the typeCode, as such a conflict would create an ambiguous situation.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.facilityType",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "XDS Facility Type.",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-facilitycodes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.healthcareFacilityTypeCode"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
}
]
},
{
"path": "DocumentReference.context.practiceSetting",
"short": "XDSDocumentEntry.practiceSettingCode",
"definition": "XDSDocumentEntry.practiceSettingCode.",
"comments": "The value set for this content has an example binding because it is a value set decided by community policy. Other examples exist for consideration: * HITSP created the table HITSP/C80 Table 2-148 Clinical Specialty Value Set (a value set based upon SNOMED CT which is referenced by Direct (XDR and XDM for Direct Messaging Specification, Version 1), as well as Nationwide Health Information Network (NHIN). Query for Documents, Web Service Interface Specification, V 3.0, 07/27/2011 * ELGA (Austria) (ELGA CDA Implementie-rungsleitfäden Registrierung von CDA Dokumenten für ELGA mit IHE Cross-Enterprise Document Sharing: XDS Metadaten (XDSDocumentEntry), [1.2.40.0.34.7.6.3] * XDS Connect-a-thon practiceSettingCode.",
"requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.practiceSetting",
"min": 0,
"max": "1"
},
"type": [
{
"code": "CodeableConcept"
}
],
"isSummary": true,
"binding": {
"strength": "example",
"description": "Additional details about where the content was created (e.g. clinical specialty).",
"valueSetReference": {
"reference": "http://hl7.org/fhir/ValueSet/c80-practice-codes"
}
},
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.practiceSettingCode"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code"
}
]
},
{
"path": "DocumentReference.context.sourcePatientInfo",
"short": "Patient demographics from source",
"definition": "The Patient Information as known when the document was published. May be a reference to a version specific, or contained.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.sourcePatientInfo",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.sourcePatientInfo DocumentEntry.sourcePatientId"
},
{
"identity": "rim",
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]"
}
]
},
{
"path": "DocumentReference.context.related",
"short": "Related identifiers or resources",
"definition": "Related identifiers or resources associated with the DocumentReference.",
"comments": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.",
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.related",
"min": 0,
"max": "*"
},
"type": [
{
"code": "BackboneElement"
}
],
"isSummary": true,
"mapping": [
{
"identity": "xds",
"map": "DocumentEntry.referenceIdList"
},
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]"
}
]
},
{
"path": "DocumentReference.context.related.id",
"representation": [
"xmlAttr"
],
"short": "xml:id (or equivalent in JSON)",
"definition": "unique id for the element within a resource (for internal references).",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.related.id",
"min": 0,
"max": "1"
},
"type": [
{
"code": "id"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.related.extension",
"short": "Additional Content defined by implementations",
"definition": "May be used to represent additional information that is not part of the basic definition of the element. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.related.extension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"mapping": [
{
"identity": "rim",
"map": "n/a"
}
]
},
{
"path": "DocumentReference.context.related.modifierExtension",
"short": "Extensions that cannot be ignored",
"definition": "May be used to represent additional information that is not part of the basic definition of the element, and that modifies the understanding of the element that contains it. Usually modifier elements provide negation or qualification. In order to make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.",
"comments": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.",
"alias": [
"extensions",
"user content",
"modifiers"
],
"min": 0,
"max": "*",
"base": {
"path": "DocumentReference.context.related.modifierExtension",
"min": 0,
"max": "*"
},
"type": [
{
"code": "Extension"
}
],
"isModifier": true,
"mapping": [
{
"identity": "rim",
"map": "N/A"
}
]
},
{
"path": "DocumentReference.context.related.identifier",
"short": "Identifier of related objects or events",
"definition": "Related identifier to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order numbers, accession numbers, XDW workflow numbers.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.related.identifier",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Identifier"
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct] .id"
}
]
},
{
"path": "DocumentReference.context.related.ref",
"short": "Related Resource",
"definition": "Related Resource to this DocumentReference. If both id and ref are present they shall refer to the same thing.",
"comments": "Order, DiagnosticOrder, Procedure, EligibilityRequest, etc.",
"min": 0,
"max": "1",
"base": {
"path": "DocumentReference.context.related.ref",
"min": 0,
"max": "1"
},
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Resource"
]
}
],
"isSummary": true,
"mapping": [
{
"identity": "rim",
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct].text.reference"
}
]
}
]
},
"differential": {
"element": [
{
"path": "DocumentReference",
"name": "XDSDocumentReference",
"short": "XDSDocumentEntry",
"definition": "A reference to a document.",
"min": 0,
"max": "*",
"type": [
{
"code": "DocumentReference"
}
]
},
{
"path": "DocumentReference.masterIdentifier",
"short": "XDSDocumentEntry.uniqueId",
"definition": "Globally unique identifier assigned to the document by the creating entity. A DocumentEntry representing a single document is identified by the uniqueId attribute; the linkage between DocumentEntry and the Document it represents is made with the uniqueId attribute. This unique identifier may be used in other documents to reference this document.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.identifier",
"short": "XDSDocumentEntry.referenceIdList",
"definition": "Other identifiers for the document."
},
{
"path": "DocumentReference.subject",
"short": "XDSDocumentEntry.patientId + sourcePatientId/sourcePatientInfo",
"definition": "The patientId represents the subject of care of the document. The value of the patientId shall be the same for all new documents of a SubmissionSet. Patient information typically includes: the patient first and last name, sex, and birth date.",
"comments": "In the context of XDS, the patientId shall be the one with use = official. The Clinical XDS Affinity Domain policies may require more or less specific information and format. This patient information is not intended to be updated once the Document is registered (just as the Document content and metadata itself will not be updated without replacing the previous document). As sourcePatientInfo may have been updated by the source actor, it may no longer be in use within the Document Source (EHR-CR). It is only intended as an audit/checking mechanism and has occasional use for Document Consumer actors.",
"min": 1,
"max": "1",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Patient"
]
}
]
},
{
"path": "DocumentReference.type",
"short": "XDSDocumentEntry.typeCode",
"definition": "The code specifying the particular kind of document (e.g. Prescription, Discharge Summary, Report). It is suggested that the XDS Affinity Domain draws these values from a coding scheme providing a coarse level of granularity (about 10 to 100 entries). Shall have a single value."
},
{
"path": "DocumentReference.class",
"short": "XDSDocumentEntry.classCode",
"definition": "A categorization for the type of the document. This may be implied by or derived from the code specified in the Document Type.",
"comments": "XDSDocumentEntry.typeCode.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.author",
"short": "XDSDocumentEntry.author",
"definition": "Represents the humans and/or machines that authored the document.",
"min": 1,
"max": "*",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
},
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Device"
]
}
]
},
{
"path": "DocumentReference.custodian",
"short": "n/a",
"definition": "Org which maintains the document.",
"min": 0,
"max": "0"
},
{
"path": "DocumentReference.authenticator",
"short": "??",
"definition": "Represents a participant who has legally authenticated or attested the document within the authorInstitution. Legal authentication implies that a document has been signed manually or electronically by the legalAuthenticator.",
"type": [
{
"code": "Reference",
"profile": [
"http://hl7.org/fhir/StructureDefinition/Practitioner"
]
}
]
},
{
"path": "DocumentReference.created",
"short": "XDSDocumentEntry.creationTime",
"definition": "Represents the time the author created the document in the Document Source.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.indexed",
"short": "XDS submission time or XDSDocumentEntry.creationTime if unknown",
"definition": "When this document reference created.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.status",
"short": "implied by XDS workflow",
"definition": "This attribute is always set to Approved as part of the submission of new XDS Documents. It may be changed to Deprecated under the primary responsibility of the Document Source with possible patient supervision. Although XDS supports the ability to delete documents, there is no such state as ???the Document Entry is removed??? (only an audit trail is kept if such a deletion is allowed)."
},
{
"path": "DocumentReference.docStatus",
"definition": "Status of the underlying document.",
"min": 0,
"max": "0"
},
{
"path": "DocumentReference.relatesTo",
"short": "Relationships that this document has with other document references that already exist",
"definition": "Relationships to other documents."
},
{
"path": "DocumentReference.relatesTo.code",
"short": "The type of relationship that this document has with anther document",
"definition": "supersedes | transforms | signs | appends.",
"comments": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document."
},
{
"path": "DocumentReference.relatesTo.target",
"short": "The target document of this relationship",
"definition": "Target of the relationship."
},
{
"path": "DocumentReference.description",
"short": "XDSDocumentEntry.title",
"definition": "Represents the title of the document."
},
{
"path": "DocumentReference.securityLabel",
"short": "XDSDocumentEntry.confidentialityCode",
"definition": "The code specifying the level of confidentiality of the XDS Document. These codes are specific to an XDS Affinity Domain.",
"comments": "Enforcement and issues related to highly sensitive documents are beyond the scope of XDS (see security section). confidentialityCode is part of a codification scheme and value set enforced by the Document Registry.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.content"
},
{
"path": "DocumentReference.content.attachment"
},
{
"path": "DocumentReference.content.attachment.contentType",
"short": "XDSDocumentEntry.mimeType",
"definition": "MIME type of the document in the Repository.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.content.attachment.language",
"short": "XDSDocumentEntry.languageCode",
"definition": "Specifies the human language of character data in the document. The values of the attribute are language identifiers as described by the IETF (Internet Engineering Task Force) RFC 3066.",
"comments": "This value may further be restricted by the registry according to XDS Affinity Domain specific policy."
},
{
"path": "DocumentReference.content.attachment.url",
"short": "repository location (by implication & configuration)",
"definition": "Where to access the document."
},
{
"path": "DocumentReference.content.attachment.size",
"short": "XDSDocumentEntry.size",
"definition": "Size in bytes of the byte stream that was provided in the Register and Provide Transaction and stored by the XDS Document Repository. This value is computed by the Document Repository and included in the Register Documents Set Transaction."
},
{
"path": "DocumentReference.content.attachment.hash",
"short": "XDSDocumentEntry.hash",
"definition": "Hash key of the XDS Document itself.",
"comments": "This value is computed by the Document Repository and used by the Document Registry for detecting the improper resubmission of XDS Documents. If present, shall have a single value. If this attribute is received in a Provide & Register Document Set-b [ITI-41] transaction, it shall be verified by the repository with the actual hash value of the submitted document; an XDSRepositoryMetadataError shall be returned on mismatch."
},
{
"path": "DocumentReference.context",
"short": "event codes, service Start & Stop time, and facility type",
"definition": "Clinical context of document - eventCodeList, serviceStart & Stop time, and facility type.",
"min": 0,
"max": "1"
},
{
"path": "DocumentReference.context.encounter",
"min": 0,
"max": "0"
},
{
"path": "DocumentReference.context.event",
"short": "XDSDocumentEntry.eventCodeList",
"definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act.",
"comments": "An event can further specialize the act inherent in the typeCode, such as where it is simply \"Procedure Report\" and the procedure was a \"colonoscopy\". If one or more eventCodes are included, they shall not conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as ???key words??? for certain types of queries."
},
{
"path": "DocumentReference.context.period",
"short": "XDSDocumentEntry.serviceStartTime & XDSDocumentEntry.serviceStopTime",
"definition": "The start and stop time of the service being documented took place.",
"comments": "At least a start date SHALL be provided.",
"min": 1,
"max": "1"
},
{
"path": "DocumentReference.context.facilityType",
"short": "XDSDocumentEntry.healthCareFacilityTypeCode",
"definition": "This code represents the type of organizational setting of the clinical encounter during which the documented act occurred.",
"comments": "In some cases, the setting of the encounter is inherent in the typeCode, such as \"Diabetes Clinic Progress Note\". healthcareFacilityTypeCode shall be equivalent to or further specialize the value inherent in the typeCode; for example, where the typeCode is simply \"Clinic Progress Note\" and the value of healthcareFacilityTypeCode is \"private clinic\". The value shall not conflict with the value inherent in the typeCode, as such a conflict would create an ambiguous situation."
},
{
"path": "DocumentReference.context.practiceSetting",
"short": "XDSDocumentEntry.practiceSettingCode",
"definition": "XDSDocumentEntry.practiceSettingCode."
}
]
}
}
© HL7.org 2011+. FHIR DSTU2 (v1.0.2-7202) generated on Sat, Oct 24, 2015 07:43+1100.
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