{
"description": "A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.",
"_filename": "DocumentReference.json",
"package_name": "hl7.fhir.r4.id.core",
"date": "2019-11-01T09:29:23+11:00",
"derivation": "specialization",
"meta": {
"lastUpdated": "2022-01-10T02:49:58.067+00:00"
},
"publisher": "Health Level Seven International (Structured Documents)",
"fhirVersion": "4.0.1",
"name": "DocumentReference",
"mapping": [ {
"uri": "http://hl7.org/fhir/workflow",
"name": "Workflow Pattern",
"identity": "workflow"
}, {
"uri": "http://hl7.org/fhir/composition",
"name": "FHIR Composition",
"identity": "fhircomposition"
}, {
"uri": "http://hl7.org/v3",
"name": "RIM Mapping",
"identity": "rim"
}, {
"uri": "http://hl7.org/v3/cda",
"name": "CDA (R2)",
"identity": "cda"
}, {
"uri": "http://hl7.org/fhir/fivews",
"name": "FiveWs Pattern Mapping",
"identity": "w5"
}, {
"uri": "http://hl7.org/v2",
"name": "HL7 v2 Mapping",
"identity": "v2"
}, {
"uri": "http://ihe.net/xds",
"name": "XDS metadata equivalent",
"identity": "xds"
} ],
"abstract": false,
"type": "DocumentReference",
"experimental": null,
"resourceType": "StructureDefinition",
"title": null,
"package_version": "0.1.0",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-category",
"valueString": "Foundation.Documents"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-standards-status",
"valueCode": "trial-use"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fmm",
"valueInteger": 3
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-security-category",
"valueCode": "not-classified"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-wg",
"valueCode": "sd"
} ],
"status": "draft",
"id": "9e38f4c2-3a3e-4f47-9a1e-91352326304e",
"kind": "resource",
"url": "https://fhir.kemkes.go.id/r4/StructureDefinition/DocumentReference",
"version": "4.0.1",
"differential": {
"element": [ {
"id": "DocumentReference",
"path": "DocumentReference",
"short": "A reference to a document",
"comment": "Usually, this is used for documents other than those defined by FHIR.",
"mapping": [ {
"map": "Event",
"identity": "workflow"
}, {
"map": "when describing a Composition",
"identity": "fhircomposition"
}, {
"map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]",
"identity": "rim"
}, {
"map": "when describing a CDA",
"identity": "cda"
} ],
"definition": "A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text."
}, {
"path": "DocumentReference.masterIdentifier",
"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.).",
"definition": "Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.",
"short": "Master Version Specific Identifier",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
}, {
"map": "Composition.identifier",
"identity": "fhircomposition"
}, {
"map": "TXA-12",
"identity": "v2"
}, {
"map": ".id",
"identity": "rim"
}, {
"map": "DocumentEntry.uniqueId",
"identity": "xds"
}, {
"map": "ClinicalDocument/id",
"identity": "cda"
} ],
"type": [ {
"code": "Identifier"
} ],
"max": "1",
"id": "DocumentReference.masterIdentifier",
"comment": "CDA Document Id extension and root.",
"isSummary": true
}, {
"id": "DocumentReference.identifier",
"path": "DocumentReference.identifier",
"type": [ {
"code": "Identifier"
} ],
"short": "Other identifiers for the document",
"mapping": [ {
"map": "Event.identifier",
"identity": "workflow"
}, {
"map": "FiveWs.identifier",
"identity": "w5"
}, {
"map": "TXA-16?",
"identity": "v2"
}, {
"map": ".id / .setId",
"identity": "rim"
}, {
"map": "DocumentEntry.entryUUID",
"identity": "xds"
} ],
"isSummary": true,
"definition": "Other identifiers associated with the document, including version independent identifiers."
}, {
"path": "DocumentReference.status",
"min": 1,
"definition": "The status of this document reference.",
"isModifier": true,
"short": "current | superseded | entered-in-error",
"mapping": [ {
"map": "Event.status",
"identity": "workflow"
}, {
"map": "FiveWs.status",
"identity": "w5"
}, {
"map": "TXA-19",
"identity": "v2"
}, {
"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": "rim"
}, {
"map": "DocumentEntry.availabilityStatus",
"identity": "xds"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/document-reference-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentReferenceStatus"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "The status of the document reference."
},
"max": "1",
"id": "DocumentReference.status",
"comment": "This is the status of the DocumentReference object, which might be independent from the docStatus element.\n\nThis element is labeled as a modifier because the status contains the codes that mark the document or reference as not currently valid.",
"isModifierReason": "This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid",
"isSummary": true
}, {
"path": "DocumentReference.docStatus",
"definition": "The status of the underlying document.",
"short": "preliminary | final | amended | entered-in-error",
"mapping": [ {
"map": "FiveWs.status",
"identity": "w5"
}, {
"map": "Composition.status",
"identity": "fhircomposition"
}, {
"map": "TXA-17",
"identity": "v2"
}, {
"map": ".statusCode",
"identity": "rim"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/composition-status|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "ReferredDocumentStatus"
} ],
"description": "Status of the underlying document."
},
"max": "1",
"id": "DocumentReference.docStatus",
"comment": "The document that is pointed to might be in various lifecycle states.",
"isSummary": true
}, {
"path": "DocumentReference.type",
"definition": "Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.",
"short": "Kind of document (LOINC if possible)",
"mapping": [ {
"map": "Event.code",
"identity": "workflow"
}, {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": "Composition.type",
"identity": "fhircomposition"
}, {
"map": "TXA-2",
"identity": "v2"
}, {
"map": "./code",
"identity": "rim"
}, {
"map": "DocumentEntry.type",
"identity": "xds"
}, {
"map": "ClinicalDocument/code/@code \n\nThe 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.",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentC80Type"
} ],
"description": "Precise type of clinical document."
},
"max": "1",
"id": "DocumentReference.type",
"comment": "Key metadata element describing the document that describes he exact type of document. Helps humans to assess whether the document is of interest when viewing a list of documents.",
"isSummary": true
}, {
"path": "DocumentReference.category",
"definition": "A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.",
"short": "Categorization of document",
"mapping": [ {
"map": "FiveWs.class",
"identity": "w5"
}, {
"map": "Composition.class",
"identity": "fhircomposition"
}, {
"map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code",
"identity": "rim"
}, {
"map": "DocumentEntry.class",
"identity": "xds"
}, {
"map": "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",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentC80Class"
} ],
"description": "High-level kind of a clinical document at a macro level."
},
"alias": [ "claxs" ],
"id": "DocumentReference.category",
"comment": "Key metadata element describing the the category or classification of the document. This is a broader perspective that groups similar documents based on how they would be used. This is a primary key used in searching.",
"isSummary": true
}, {
"id": "DocumentReference.subject",
"max": "1",
"path": "DocumentReference.subject",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/Group", "http://hl7.org/fhir/StructureDefinition/Device" ]
} ],
"short": "Who/what is the subject of the document",
"mapping": [ {
"map": "Event.subject",
"identity": "workflow"
}, {
"map": "FiveWs.subject[x]",
"identity": "w5"
}, {
"map": "Composition.subject",
"identity": "fhircomposition"
}, {
"map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)",
"identity": "v2"
}, {
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]",
"identity": "rim"
}, {
"map": "DocumentEntry.patientId",
"identity": "xds"
}, {
"map": "ClinicalDocument/recordTarget/",
"identity": "cda"
}, {
"map": "FiveWs.subject",
"identity": "w5"
} ],
"isSummary": true,
"definition": "Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure)."
}, {
"path": "DocumentReference.date",
"definition": "When the document reference was created.",
"short": "When this document reference was created",
"mapping": [ {
"map": "Event.occurrence[x]",
"identity": "workflow"
}, {
"map": "FiveWs.recorded",
"identity": "w5"
}, {
"map": "Composition.date",
"identity": "fhircomposition"
}, {
"map": ".availabilityTime[type=\"TS\"]",
"identity": "rim"
} ],
"type": [ {
"code": "instant"
} ],
"alias": [ "indexed" ],
"max": "1",
"id": "DocumentReference.date",
"comment": "Referencing/indexing time is used for tracking, organizing versions and searching.",
"isSummary": true
}, {
"id": "DocumentReference.author",
"path": "DocumentReference.author",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization", "http://hl7.org/fhir/StructureDefinition/Device", "http://hl7.org/fhir/StructureDefinition/Patient", "http://hl7.org/fhir/StructureDefinition/RelatedPerson" ]
} ],
"short": "Who and/or what authored the document",
"comment": "Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).",
"mapping": [ {
"map": "Event.performer.actor",
"identity": "workflow"
}, {
"map": "Composition.author",
"identity": "fhircomposition"
}, {
"map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)",
"identity": "v2"
}, {
"map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": "DocumentEntry.author",
"identity": "xds"
}, {
"map": "ClinicalDocument/author",
"identity": "cda"
} ],
"isSummary": true,
"definition": "Identifies who is responsible for adding the information to the document."
}, {
"id": "DocumentReference.authenticator",
"max": "1",
"path": "DocumentReference.authenticator",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Practitioner", "http://hl7.org/fhir/StructureDefinition/PractitionerRole", "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"short": "Who/what authenticated the document",
"comment": "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.",
"mapping": [ {
"map": "Event.performer.actor",
"identity": "workflow"
}, {
"map": "FiveWs.witness",
"identity": "w5"
}, {
"map": "Composition.attester",
"identity": "fhircomposition"
}, {
"map": "TXA-10",
"identity": "v2"
}, {
"map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]",
"identity": "rim"
}, {
"map": "DocumentEntry.legalAuthenticator",
"identity": "xds"
}, {
"map": "ClinicalDocument/legalAuthenticator",
"identity": "cda"
} ],
"definition": "Which person or organization authenticates that this document is valid."
}, {
"id": "DocumentReference.custodian",
"max": "1",
"path": "DocumentReference.custodian",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ]
} ],
"short": "Organization which maintains the document",
"comment": "Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.",
"mapping": [ {
"map": "Event.performer.actor",
"identity": "workflow"
}, {
"map": "Composition.custodian",
"identity": "fhircomposition"
}, {
"map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]",
"identity": "rim"
} ],
"definition": "Identifies the organization or group who is responsible for ongoing maintenance of and access to the document."
}, {
"id": "DocumentReference.relatesTo",
"path": "DocumentReference.relatesTo",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Relationships to other documents",
"comment": "This element is labeled as a modifier because documents that append to other documents are incomplete on their own.",
"mapping": [ {
"map": "Composition.relatesTo",
"identity": "fhircomposition"
}, {
"map": ".outboundRelationship",
"identity": "rim"
}, {
"map": "DocumentEntry Associations",
"identity": "xds"
} ],
"isSummary": true,
"definition": "Relationships that this document has with other document references that already exist."
}, {
"path": "DocumentReference.relatesTo.code",
"min": 1,
"definition": "The type of relationship that this document has with anther document.",
"short": "replaces | transforms | signs | appends",
"mapping": [ {
"map": "Composition.relatesTo.code",
"identity": "fhircomposition"
}, {
"map": ".outboundRelationship.typeCode",
"identity": "rim"
}, {
"map": "DocumentEntry Associations type",
"identity": "xds"
} ],
"type": [ {
"code": "code"
} ],
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentRelationshipType"
} ],
"description": "The type of relationship between documents."
},
"max": "1",
"id": "DocumentReference.relatesTo.code",
"comment": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.",
"isSummary": true
}, {
"path": "DocumentReference.relatesTo.target",
"min": 1,
"definition": "The target document of this relationship.",
"short": "Target of the relationship",
"mapping": [ {
"map": "Composition.relatesTo.target",
"identity": "fhircomposition"
}, {
"map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id",
"identity": "rim"
}, {
"map": "DocumentEntry Associations reference",
"identity": "xds"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ]
} ],
"max": "1",
"id": "DocumentReference.relatesTo.target",
"isSummary": true
}, {
"path": "DocumentReference.description",
"requirements": "Helps humans to assess whether the document is of interest.",
"definition": "Human-readable description of the source document.",
"short": "Human-readable description",
"mapping": [ {
"map": "TXA-25",
"identity": "v2"
}, {
"map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text",
"identity": "rim"
}, {
"map": "DocumentEntry.comments",
"identity": "xds"
} ],
"type": [ {
"code": "string"
} ],
"max": "1",
"id": "DocumentReference.description",
"comment": "What the document is about, a terse summary of the document.",
"isSummary": true
}, {
"path": "DocumentReference.securityLabel",
"requirements": "Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.",
"definition": "A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the \"reference\" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.",
"short": "Document security-tags",
"mapping": [ {
"map": "Composition.confidentiality, Composition.meta.security",
"identity": "fhircomposition"
}, {
"map": "TXA-18",
"identity": "v2"
}, {
"map": ".confidentialityCode",
"identity": "rim"
}, {
"map": "DocumentEntry.confidentialityCode",
"identity": "xds"
}, {
"map": "ClinicalDocument/confidentialityCode/@code",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "extensible",
"valueSet": "http://hl7.org/fhir/ValueSet/security-labels",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "SecurityLabels"
}, {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-isCommonBinding",
"valueBoolean": true
} ],
"description": "Security Labels from the Healthcare Privacy and Security Classification System."
},
"id": "DocumentReference.securityLabel",
"comment": "The confidentiality codes can carry multiple vocabulary items. HL7 has developed an understanding of security and privacy tags that might be desirable in a Document Sharing environment, called HL7 Healthcare Privacy and Security Classification System (HCS). The following specification is recommended but not mandated, as the vocabulary bindings are an administrative domain responsibility. The use of this method is up to the policy domain such as the XDS Affinity Domain or other Trust Domain where all parties including sender and recipients are trusted to appropriately tag and enforce. \n\nIn the HL7 Healthcare Privacy and Security Classification (HCS) there are code systems specific to Confidentiality, Sensitivity, Integrity, and Handling Caveats. Some values would come from a local vocabulary as they are related to workflow roles and special projects.",
"isSummary": true
}, {
"id": "DocumentReference.content",
"min": 1,
"path": "DocumentReference.content",
"type": [ {
"code": "BackboneElement"
} ],
"short": "Document referenced",
"mapping": [ {
"map": "Bundle(Composition+*)",
"identity": "fhircomposition"
}, {
"map": "document.text",
"identity": "rim"
} ],
"isSummary": true,
"definition": "The document and format referenced. There may be multiple content element repetitions, each with a different format."
}, {
"path": "DocumentReference.content.attachment",
"min": 1,
"definition": "The document or URL of the document along with critical metadata to prove content has integrity.",
"short": "Where to access the document",
"mapping": [ {
"map": "Composition.language, \nComposition.title, \nComposition.date",
"identity": "fhircomposition"
}, {
"map": "TXA-3 for mime type",
"identity": "v2"
}, {
"map": "document.text",
"identity": "rim"
}, {
"map": "DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime",
"identity": "xds"
}, {
"map": "ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date",
"identity": "cda"
} ],
"type": [ {
"code": "Attachment"
} ],
"max": "1",
"id": "DocumentReference.content.attachment",
"isSummary": true
}, {
"path": "DocumentReference.content.format",
"definition": "An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.",
"short": "Format/content rules for the document",
"mapping": [ {
"map": "Composition.meta.profile",
"identity": "fhircomposition"
}, {
"map": "document.text",
"identity": "rim"
}, {
"map": "DocumentEntry.formatCode",
"identity": "xds"
}, {
"map": "derived from the IHE Profile or Implementation Guide templateID",
"identity": "cda"
} ],
"type": [ {
"code": "Coding"
} ],
"binding": {
"strength": "preferred",
"valueSet": "http://hl7.org/fhir/ValueSet/formatcodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentFormat"
} ],
"description": "Document Format Codes."
},
"max": "1",
"id": "DocumentReference.content.format",
"comment": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.",
"isSummary": true
}, {
"path": "DocumentReference.context",
"definition": "The clinical context in which the document was prepared.",
"short": "Clinical context of document",
"mapping": [ {
"map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']",
"identity": "rim"
} ],
"type": [ {
"code": "BackboneElement"
} ],
"max": "1",
"id": "DocumentReference.context",
"comment": "These values are primarily added to help with searching for interesting/relevant documents.",
"isSummary": true
}, {
"id": "DocumentReference.context.encounter",
"path": "DocumentReference.context.encounter",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare" ]
} ],
"short": "Context of the document content",
"mapping": [ {
"map": "Event.context",
"identity": "workflow"
}, {
"map": "FiveWs.context",
"identity": "w5"
}, {
"map": "Composition.encounter",
"identity": "fhircomposition"
}, {
"map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])",
"identity": "rim"
} ],
"definition": "Describes the clinical encounter or type of care that the document content is associated with."
}, {
"id": "DocumentReference.context.event",
"path": "DocumentReference.context.event",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Main clinical acts documented",
"binding": {
"strength": "example",
"valueSet": "http://terminology.hl7.org/ValueSet/v3-ActCode",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentEventType"
} ],
"description": "This list of codes represents the main clinical acts being documented."
},
"comment": "An event can further specialize the act inherent in the type, such as where it is simply \"Procedure Report\" and the procedure was a \"colonoscopy\". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.",
"mapping": [ {
"map": "Composition.event.code",
"identity": "fhircomposition"
}, {
"map": ".code",
"identity": "rim"
}, {
"map": "DocumentEntry.eventCodeList",
"identity": "xds"
} ],
"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 type Code, such as a \"History and Physical Report\" in which the procedure being documented is necessarily a \"History and Physical\" act."
}, {
"id": "DocumentReference.context.period",
"max": "1",
"path": "DocumentReference.context.period",
"type": [ {
"code": "Period"
} ],
"short": "Time of service that is being documented",
"mapping": [ {
"map": "Composition.event.period",
"identity": "fhircomposition"
}, {
"map": ".effectiveTime",
"identity": "rim"
}, {
"map": "DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime",
"identity": "xds"
}, {
"map": "ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/low/\n@value --> ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/high/\n@value",
"identity": "cda"
} ],
"isSummary": true,
"definition": "The time period over which the service that is described by the document was provided."
}, {
"id": "DocumentReference.context.facilityType",
"max": "1",
"path": "DocumentReference.context.facilityType",
"type": [ {
"code": "CodeableConcept"
} ],
"short": "Kind of facility where patient was seen",
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/c80-facilitycodes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentC80FacilityType"
} ],
"description": "XDS Facility Type."
},
"mapping": [ {
"map": "usually from a mapping to a local ValueSet",
"identity": "fhircomposition"
}, {
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code",
"identity": "rim"
}, {
"map": "DocumentEntry.healthcareFacilityTypeCode",
"identity": "xds"
}, {
"map": "usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code",
"identity": "cda"
} ],
"definition": "The kind of facility where the patient was seen."
}, {
"path": "DocumentReference.context.practiceSetting",
"requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.",
"definition": "This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.",
"short": "Additional details about where the content was created (e.g. clinical specialty)",
"mapping": [ {
"map": "usually from a mapping to a local ValueSet",
"identity": "fhircomposition"
}, {
"map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code",
"identity": "rim"
}, {
"map": "DocumentEntry.practiceSettingCode",
"identity": "xds"
}, {
"map": "usually from a mapping to a local ValueSet",
"identity": "cda"
} ],
"type": [ {
"code": "CodeableConcept"
} ],
"binding": {
"strength": "example",
"valueSet": "http://hl7.org/fhir/ValueSet/c80-practice-codes",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "DocumentC80PracticeSetting"
} ],
"description": "Additional details about where the content was created (e.g. clinical specialty)."
},
"max": "1",
"id": "DocumentReference.context.practiceSetting",
"comment": "This element should be based on a coarse classification system for the class of specialty practice. Recommend the use of the classification system for Practice Setting, such as that described by the Subject Matter Domain in LOINC."
}, {
"id": "DocumentReference.context.sourcePatientInfo",
"max": "1",
"path": "DocumentReference.context.sourcePatientInfo",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient" ]
} ],
"short": "Patient demographics from source",
"mapping": [ {
"map": "Composition.subject",
"identity": "fhircomposition"
}, {
"map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]",
"identity": "rim"
}, {
"map": "DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId",
"identity": "xds"
}, {
"map": "ClinicalDocument/recordTarget/",
"identity": "cda"
} ],
"definition": "The Patient Information as known when the document was published. May be a reference to a version specific, or contained."
}, {
"id": "DocumentReference.context.related",
"path": "DocumentReference.context.related",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ]
} ],
"short": "Related identifiers or resources",
"comment": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.",
"mapping": [ {
"map": "Composition.event.detail",
"identity": "fhircomposition"
}, {
"map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]",
"identity": "rim"
}, {
"map": "DocumentEntry.referenceIdList",
"identity": "xds"
}, {
"map": "ClinicalDocument/relatedDocument",
"identity": "cda"
} ],
"definition": "Related identifiers or resources associated with the DocumentReference."
} ]
},
"contact": [ {
"telecom": [ {
"value": "http://hl7.org/fhir",
"system": "url"
} ]
}, {
"telecom": [ {
"value": "http://www.hl7.org/Special/committees/structure/index.cfm",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DomainResource"
}