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10.2.9 Resource DocumentReference - Mappings

Orders and Observations icon Work GroupMaturity Level: N/AStandards Status: InformativeSecurity Category: Not Classified Compartments: Device, Encounter, Group, 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 icon)

DocumentReference infrastructure.documents
    identifier FiveWs.identifier
    version FiveWs.version
    status FiveWs.status
    docStatus FiveWs.status
    modality FiveWs.class
    type FiveWs.what[x]
    category FiveWs.what[x]
    subject FiveWs.subject[x]
    context FiveWs.context
    period FiveWs.done[x]
    date FiveWs.recorded
    author FiveWs.author
        party FiveWs.witness

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

DocumentReference Event
    identifier Event.identifier
    basedOn Event.basedOn
    status Event.status
    type Event.code
    category Event.category
    subject Event.subject
    context Event.encounter
    period Event.occurrence[x]
    date Event.recorded
    author Event.performer.actor

10.2.9.3 HL7 V2 Mapping (http://hl7.org/v2 icon)

DocumentReference
    identifier TXA-12
    version
    basedOn
    status TXA-19
    docStatus TXA-17
    modality
    type TXA-2
    category
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 V2 MDM message)
    context
    event
    related
    bodySite
    facilityType
    practiceSetting
    period
    date
    author TXA-9 (No standard way to indicate a Device in HL7 V2 MDM message)
    attester
        mode
        time
        party TXA-10
    custodian
    relatesTo
        code
        target
    description TXA-25
    securityLabel TXA-18
    content
        attachment TXA-3 for mime type
        profile
            value[x]

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

DocumentReference when describing a CDA
    identifier ClinicalDocument/id
    version
    basedOn
    status
    docStatus
    modality
    type ClinicalDocument/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.
    category Derived 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
    subject ClinicalDocument/recordTarget/
    context
    event
    related
    bodySite
    facilityType usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
    practiceSetting usually from a mapping to a local ValueSet
    period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
    date
    author ClinicalDocument/author
    attester .authenticator/.legalAuthenticator
        mode implied by .authenticator/.legalAuthenticator
        time .authenticator.time
        party .authenticator.assignedEnttty
    custodian
    relatesTo
        code ClinicalDocument/relatedDocument/typeCode
        target ClinicalDocument/relatedDocument/parentDocument
    description
    securityLabel ClinicalDocument/confidentialityCode/@code
    content
        attachment ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        profile derived from the IHE Profile or Implementation Guide templateID
            value[x] derived from the IHE Profile or Implementation Guide templateID

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

DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    identifier .id / .setId
    basedOn .outboundRelationship[typeCode=FLFS].target
    status 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"
    docStatus .statusCode
    type ./code
    category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    subject .participation[typeCode="SBJ"].role[typeCode="PAT"]
    context unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
    event .code
    related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
    bodySite .targetSiteCode
    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"]
        mode unique(./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
    content document.text
        attachment document.text
        profile document.text
            value[x] document.text

10.2.9.6 XDS metadata equivalent (https://profiles.ihe.net/ITI/TF/Volume3 icon)

DocumentReference DocumentEntry
    identifier DocumentEntry.entryUUID, DocumentEntry.uniqueId
    version
    basedOn DocumentEntry.referenceIdList
    status DocumentEntry.availabilityStatus
    docStatus
    modality
    type DocumentEntry.typeCode
    category DocumentEntry.classCode
    subject DocumentEntry.patientId
    context
    event DocumentEntry.eventCodeList
    related DocumentEntry.referenceIdList
    bodySite
    facilityType DocumentEntry.healthcareFacilityTypeCode
    practiceSetting DocumentEntry.practiceSettingCode
    period DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
    date
    author DocumentEntry.author
    attester DocumentEntry.legalAuthenticator
        mode
        time
        party
    custodian
    relatesTo DocumentEntry Associations
        code DocumentEntry Associations type
        target DocumentEntry Associations reference
    description DocumentEntry.comments
    securityLabel DocumentEntry.confidentialityCode
    content
        attachment DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.repositoryUniqueId, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        profile DocumentEntry.formatCode
            value[x] DocumentEntry.formatCode

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

DocumentReference when describing a Composition
    identifier Composition.identifier
    version Composition.version
    basedOn
    status
    docStatus Composition.status
    modality
    type Composition.type
    category Composition.category
    subject Composition.subject
    context Composition.encounter
    event Composition.event.detail
    related Composition.event.detail
    bodySite
    facilityType usually from a mapping to a local ValueSet
    practiceSetting usually from a mapping to a local ValueSet
    period Composition.event.period
    date Composition.date
    author Composition.author
    attester Composition.attester
        mode Composition.attester.mode
        time Composition.attester.time
        party Composition.attester.party
    custodian Composition.custodian
    relatesTo Composition.relatesTo
        code Composition.relatesTo.type
        target Composition.relatesTo.targetReference
    description
    securityLabel Bundle.meta.security
    content Bundle(Composition+*)
        attachment Composition.language,
Composition.title,
Composition.date
        profile Composition.meta.profile
            value[x] Composition.meta.profile