{
"description": "Imaging research including images and reports.",
"_filename": "StructureDefinition-bbs-DocumentReference.json",
"package_name": "medmij.fhir.nl.r4.imageavailability",
"date": null,
"derivation": "constraint",
"publisher": "MedMij",
"fhirVersion": "4.0.1",
"purpose": "This DocumentReference resource represents the Onderzoek building block for patient use cases in the context of the information standard [Image Availability (Beeldbeschikbaarheid)](https://informatiestandaarden.nictiz.nl/wiki/Landingspagina_Beeldbeschikbaarheid). This profile is based on the [IHE.MHD.UnContained.Comprehensive.DocumentReference profile](https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.UnContained.Comprehensive.DocumentReference).",
"name": "BbsDocumentReference",
"mapping": [ {
"uri": "https://decor.nictiz.nl/pub/bbs/bbs-html-20240208T092809/ds-2.16.840.1.113883.2.4.3.11.60.133.1.1-2022-03-09T122352.html",
"name": "ART-DECOR Dataset BBS 1.0.0-alpha.2 20240208",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"name": "Dataset Beeldbeschikbaarheid MedMij 1.0.0-beta.1 20250807",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"name": "Dataset Beeldbeschikbaarheid MedMij 1.0.0-rc.1 20250919",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
}, {
"uri": "https://decor.nictiz.nl/pub/nihemds/ihexds-html-20220712T144728/ds-2.16.840.1.113883.2.4.3.11.60.106.1.1-2013-12-04T122419.html",
"name": "ART-DECOR Dataset Nationale IHE MetaData Set (2024)",
"identity": "ihexds-dataset-2024-20220712"
} ],
"abstract": false,
"copyright": "Copyright and related rights waived via CC0, https://creativecommons.org/publicdomain/zero/1.0/. This does not apply to information from third parties, for example a medical terminology system. The implementer alone is responsible for identifying and obtaining any necessary licenses or authorizations to utilize third party IP in connection with the specification or otherwise.",
"type": "DocumentReference",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "bbs DocumentReference",
"package_version": "1.0.0-rc.1",
"status": "active",
"id": "d9d184a3-a77b-47a5-bb36-0183a898c72b",
"kind": "resource",
"url": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference",
"version": null,
"differential": {
"element": [ {
"id": "DocumentReference",
"path": "DocumentReference",
"alias": [ "Onderzoek" ],
"short": "ImagingResearch",
"mapping": [ {
"map": "bbs-dataelement-66",
"comment": "ImagingResearch",
"identity": "bbs-dataset-100-alpha2-20240208"
} ],
"constraint": [ {
"key": "bbs-DocumentReference-1",
"human": "Either a category for an image or a report is present.",
"source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference",
"severity": "error",
"expression": "category.coding.where(system = 'urn:oid:1.3.6.1.4.1.19376.1.2.6.1' and code = 'IMAGES').exists() xor category.coding.where(system = 'urn:oid:1.3.6.1.4.1.19376.1.2.6.1' and code = 'REPORTS').exists()"
}, {
"key": "bbs-DocumentReference-2",
"human": "For an image or series of images the modalities are specified.",
"source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference",
"severity": "error",
"expression": "category.coding.where(system = 'urn:oid:1.3.6.1.4.1.19376.1.2.6.1' and code = 'IMAGES').exists() implies context.event.coding.where(system = 'http://dicom.nema.org/resources/ontology/DCM').exists()"
} ],
"definition": "Imaging research including images and reports."
}, {
"id": "DocumentReference.masterIdentifier",
"path": "DocumentReference.masterIdentifier",
"alias": [ "VerslaginformatieIdentificatienummer", "BeeldinformatieIdentificatienummer" ],
"short": "ReportInformationIdentificationNumber / ImageInformationIdentificationNumber / UniqueID",
"mapping": [ {
"map": "bbs-dataelement-100",
"comment": "ReportInformationIdentificationNumber",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "bbs-dataelement-784",
"comment": "ImageInformationIdentificationNumber",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-29",
"comment": "uniqueID",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* Globally unique ID for the report of the imaging research. In DICOM the study/series UID can be used.\n* Globally unique ID that describes the set of images. In DICOM the study/series UID can be used.\n* The globally unique identifier assigned by the document creator to this document."
}, {
"id": "DocumentReference.status",
"path": "DocumentReference.status",
"short": "AvailabilityStatus",
"mapping": [ {
"map": "ihexds-dataelement-3",
"comment": "availabilityStatus",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "The lifecycle status of the document.",
"patternCode": "current"
}, {
"id": "DocumentReference.type",
"path": "DocumentReference.type",
"alias": [ "VerrichtingType" ],
"short": "ProcedureType / TypeCode",
"binding": {
"strength": "extensible",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.133.11.1--20230808113539"
},
"comment": "The value set bound to this element is a thesaurus managed, owned and distributed by DHD (namely the Verrichtingenthesaurus (VT)). Every concept in the VT is linked to a unique SNOMED concept, but it is no SNOMED reference set, and in particular it is not published on the SNOMED browsers. In order to retrieve the contents of the VT, authorized access is required.\n\nThe XDS metadata element typeCode, which normally contains the precise type of document, is mapped on `.type` in [core FHIR](https://hl7.org/fhir/R4/documentreference-mappings.html#xds). In XDS-I, and consequently, the Nictiz IG, the typeCode element is used to indicate the procedure type instead. Even though `.context.event` is better suited to convey the procedure type from a FHIR perspective, the core FHIR mapping between typeCode and `.type` is retained.",
"mapping": [ {
"map": "bbs-dataelement-176",
"comment": "ProcedureType",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-28",
"comment": "typeCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* Description of the procedure and/or the performed imaging research (e.g. CT thorax, MRI knee, ultrasonography of breast, X-ray).\n* The code specifying the precise kind of document (e.g. Pulmonary History and Physical, Discharge Summary, Ultrasound Report)."
}, {
"id": "DocumentReference.category",
"path": "DocumentReference.category",
"short": "ClassCode",
"mapping": [ {
"map": "ihexds-dataelement-9",
"comment": "classCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "The code specifying the particular kind of document."
}, {
"id": "DocumentReference.category.coding",
"min": 1,
"path": "DocumentReference.category.coding",
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
}
}, {
"id": "DocumentReference.category.coding:images",
"max": "1",
"min": 0,
"path": "DocumentReference.category.coding",
"condition": [ "bbs-DocumentReference-1", "bbs-DocumentReference-2" ],
"sliceName": "images",
"patternCoding": {
"code": "IMAGES",
"system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1"
}
}, {
"id": "DocumentReference.category.coding:reports",
"max": "1",
"min": 0,
"path": "DocumentReference.category.coding",
"condition": [ "bbs-DocumentReference-1" ],
"sliceName": "reports",
"patternCoding": {
"code": "REPORTS",
"system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1"
}
}, {
"id": "DocumentReference.subject",
"path": "DocumentReference.subject",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ]
} ],
"alias": [ "Patient" ],
"short": "Patient / PatientId",
"mapping": [ {
"map": "bbs-dataelement-132",
"comment": "Patient",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-19",
"comment": "patientId",
"identity": "ihexds-dataset-2024-20220712"
} ]
}, {
"id": "DocumentReference.date",
"min": 1,
"path": "DocumentReference.date",
"alias": [ "DatumTijd" ],
"short": "DateTime / CreationTime",
"mapping": [ {
"map": "bbs-dataelement-101",
"comment": "DateTime",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "bbs-dataelement-69",
"comment": "DateTime",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-11",
"comment": "creationTime",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* Date/time on which the report has been autorised and/or made available (if the DocumentReference represents an imaging report).\n* Date/time on which the radiological examination has been performed on the patient and/or the images have been made (if the DocumentReference represents an imaging study).\n* The time the author created the document. Shall have a single value."
}, {
"id": "DocumentReference.author",
"min": 1,
"path": "DocumentReference.author",
"short": "Author",
"mapping": [ {
"map": "ihexds-dataelement-2",
"comment": "author",
"identity": "ihexds-dataset-2024-20220712"
} ],
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "resolve()",
"type": "profile"
} ]
}
}, {
"path": "DocumentReference.author",
"min": 1,
"definition": "The healthcare center where the procedure was, is or will be carried out.",
"short": "Location",
"mapping": [ {
"map": "bbs-dataelement-185",
"comment": "Location",
"identity": "bbs-dataset-100-alpha2-20240208"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ]
} ],
"sliceName": "location",
"alias": [ "Locatie" ],
"max": "1",
"id": "DocumentReference.author:location"
}, {
"path": "DocumentReference.author",
"min": 0,
"definition": "The health professional who carried out or will carry out the procedure. In most cases, only the medical specialty is entered, and not the name of the health professional. In the context of image exchange, the Performing Physician should be conveyed here, and NOT the laboratory technician who makes the images (i.e. the Operator).",
"short": "Performer",
"mapping": [ {
"map": "bbs-dataelement-187",
"comment": "Performer",
"identity": "bbs-dataset-100-alpha2-20240208"
} ],
"type": [ {
"code": "Reference",
"targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole" ]
} ],
"sliceName": "performer",
"alias": [ "Uitvoerder" ],
"max": "*",
"id": "DocumentReference.author:performer",
"comment": "Each occurrence of the zib HealthProfessional is normally represented by _two_ FHIR resources: a PractitionerRole resource (instance of [nl-core-HealthProfessional-PractitionerRole](http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole)) and a Practitioner resource (instance of [nl-core-HealthProfessional-Practitioner](http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-Practitioner)). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance.\n\nIn rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the nl-core-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile."
}, {
"id": "DocumentReference.authenticator",
"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", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ]
} ],
"short": "LegalAuthenticator",
"comment": "Each occurrence of the zib HealthProfessional is normally represented by _two_ FHIR resources: a PractitionerRole resource (instance of [nl-core-HealthProfessional-PractitionerRole](http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole)) and a Practitioner resource (instance of [nl-core-HealthProfessional-Practitioner](http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-Practitioner)). The Practitioner resource is referenced from the PractitionerRole instance. For this reason, sending systems should fill the reference to the PractitionerRole instance here, and not the Practitioner resource. Receiving systems can then retrieve the reference to the Practitioner resource from that PractitionerRole instance.\n\nIn rare circumstances, there is only a Practitioner instance, in which case it is that instance which will be referenced here. However, since this should be the exception, the nl-core-HealthProfessional-Practitioner profile is not explicitly mentioned as a target profile.",
"mapping": [ {
"map": "ihexds-dataelement-17",
"comment": "legalAuthenticator",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Represents a participant who has legally authenticated or attested the document within the author institution."
}, {
"id": "DocumentReference.description",
"path": "DocumentReference.description",
"short": "Comments",
"mapping": [ {
"map": "ihexds-dataelement-4",
"comment": "comments",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Comments associated with the document."
}, {
"id": "DocumentReference.securityLabel",
"path": "DocumentReference.securityLabel",
"short": "ConfidentialityCode",
"binding": {
"strength": "extensible",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.6--20131212104106"
},
"mapping": [ {
"map": "ihexds-dataelement-10",
"comment": "confidentialityCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "The code specifying the level of confidentiality of the document."
}, {
"id": "DocumentReference.content.attachment.contentType",
"path": "DocumentReference.content.attachment.contentType",
"short": "MimeType",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/mimetypes|4.0.1",
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName",
"valueString": "MimeType"
}, {
"url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding",
"extension": [ {
"url": "key",
"valueId": "bbs-DocumentReference-binding-contentType-1"
}, {
"url": "purpose",
"valueCode": "extensible"
}, {
"url": "valueSet",
"valueCanonical": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.8--20131212104106"
} ]
} ],
"description": "The mime type of an attachment. Any valid mime type is allowed."
},
"mapping": [ {
"map": "ihexds-dataelement-18",
"comment": "mimeType",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "MIME type of the document."
}, {
"id": "DocumentReference.content.attachment.language",
"path": "DocumentReference.content.attachment.language",
"short": "LanguageCode",
"binding": {
"strength": "extensible",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.12--20131212104106"
},
"mapping": [ {
"map": "ihexds-dataelement-16",
"comment": "languageCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Specifies the human language of character data in the document. Using codes from IETF RFC 3066."
}, {
"id": "DocumentReference.content.attachment.url",
"path": "DocumentReference.content.attachment.url",
"short": "URI",
"mapping": [ {
"map": "ihexds-dataelement-30",
"comment": "URI",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "The URI for the document."
}, {
"id": "DocumentReference.content.attachment.size",
"path": "DocumentReference.content.attachment.size",
"short": "Size",
"mapping": [ {
"map": "ihexds-dataelement-24",
"comment": "size",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Size in bytes of the document."
}, {
"id": "DocumentReference.content.attachment.hash",
"path": "DocumentReference.content.attachment.hash",
"short": "Hash",
"mapping": [ {
"map": "ihexds-dataelement-14",
"comment": "hash",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Hash of the document itself."
}, {
"id": "DocumentReference.content.attachment.title",
"path": "DocumentReference.content.attachment.title",
"alias": [ "VerslagTitel", "BeeldTitel" ],
"short": "ReportTitle / ImageTitle / Title",
"mapping": [ {
"map": "bbs-medmij-dataelement-2",
"comment": "ReportTitle",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"map": "bbs-medmij-dataelement-1",
"comment": "ImageTitle",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"map": "bbs-medmij-dataelement-2",
"comment": "ReportTitle",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
}, {
"map": "bbs-medmij-dataelement-1",
"comment": "ImageTitle",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
}, {
"map": "ihexds-dataelement-27",
"comment": "title",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* The title of the report.\n* The title of the image.\n* The title of the document."
}, {
"id": "DocumentReference.content.attachment.creation",
"path": "DocumentReference.content.attachment.creation",
"alias": [ "DatumTijd" ],
"short": "DateTime / CreationTime",
"mapping": [ {
"map": "bbs-dataelement-101",
"comment": "DateTime",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "bbs-dataelement-69",
"comment": "DateTime",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-11",
"comment": "creationTime",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* Date/time on which the report has been autorised and/or made available (if the DocumentReference represents an imaging report).\n* Date/time on which the radiological examination has been performed on the patient and/or the images have been made (if the DocumentReference represents an imaging study).\n* The time the author created the document. Shall have a single value."
}, {
"id": "DocumentReference.content.format",
"path": "DocumentReference.content.format",
"short": "FormatCode",
"binding": {
"strength": "extensible",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.7--20131212104106"
},
"mapping": [ {
"map": "ihexds-dataelement-13",
"comment": "formatCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "Code globally uniquely specifying the format of the document."
}, {
"id": "DocumentReference.context.encounter",
"path": "DocumentReference.context.encounter",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Encounter" ]
} ],
"short": "ReferenceIdList",
"comment": "Only Encounters on the ReferenceIdList are conveyed here, while other identifiers on that list are conveyed via `.context.related`.",
"mapping": [ {
"map": "ihexds-dataelement-117",
"comment": "referenceIdList",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "A list of identifiers that apply to the document. Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDS Workflow Instance Identifiers, etc."
}, {
"id": "DocumentReference.context.event",
"path": "DocumentReference.context.event",
"short": "EventCodeList",
"mapping": [ {
"map": "ihexds-dataelement-12",
"comment": "eventCodeList",
"identity": "ihexds-dataset-2024-20220712"
} ],
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "$this",
"type": "value"
} ]
},
"definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented."
}, {
"path": "DocumentReference.context.event",
"min": 0,
"definition": "Anatomical location which is the focus of the procedure.\n\nThe value set is proposed by IHE MCWG and also suggested for the EU (Xt-EHR). The used value set is a subset of the value set defined in zib2020.",
"short": "ProcedureAnatomicalLocation / Location",
"mapping": [ {
"map": "bbs-dataelement-178",
"comment": "ProcedureAnatomicalLocation",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "bbs-dataelement-179",
"comment": "Location",
"identity": "bbs-dataset-100-alpha2-20240208"
} ],
"type": [ {
"code": "CodeableConcept",
"profile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-AnatomicalLocation" ]
} ],
"sliceName": "procedureAnatomicalLocation",
"binding": {
"strength": "required",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.19--20240205123345"
},
"alias": [ "VerrichtingAnatomischeLocatie", "Locatie" ],
"max": "1",
"id": "DocumentReference.context.event:procedureAnatomicalLocation"
}, {
"id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality",
"path": "DocumentReference.context.event.extension",
"sliceName": "laterality"
}, {
"id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality.value[x]",
"path": "DocumentReference.context.event.extension.value[x]",
"mapping": [ {
"map": "bbs-dataelement-180",
"comment": "Laterality",
"identity": "bbs-dataset-100-alpha2-20240208"
} ]
}, {
"path": "DocumentReference.context.event",
"min": 0,
"definition": "Type of medical imaging device, process or method that originally acquired or produced the data used to create the image or series of images, such as a CT scanner or MRI machine.",
"short": "Modality",
"mapping": [ {
"map": "bbs-medmij-dataelement-5",
"comment": "Modality",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"map": "bbs-medmij-dataelement-5",
"comment": "Modality",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
} ],
"sliceName": "modality",
"binding": {
"strength": "required",
"valueSet": "http://medmij.nl/fhir/ValueSet/ModalityCombined",
"extension": [ {
"url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding",
"extension": [ {
"url": "key",
"valueId": "bbs-DocumentReference-binding-modality-1"
}, {
"url": "purpose",
"valueCode": "minimum"
}, {
"url": "valueSet",
"valueCanonical": "http://medmij.nl/fhir/ValueSet/Modality"
} ]
} ]
},
"alias": [ "Modaliteit" ],
"max": "*",
"id": "DocumentReference.context.event:modality",
"condition": [ "bbs-DocumentReference-2" ],
"comment": "For an image or series of images the modalities SHALL be specified."
}, {
"id": "DocumentReference.context.period",
"min": 1,
"path": "DocumentReference.context.period"
}, {
"id": "DocumentReference.context.period.start",
"min": 1,
"path": "DocumentReference.context.period.start",
"alias": [ "VerrichtingStartDatum" ],
"short": "ProcedureStartDate / ServiceStartTime",
"mapping": [ {
"map": "bbs-dataelement-174",
"comment": "ProcedureStartDate",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-22",
"comment": "serviceStartTime",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* Date/time on which the radiological examination has been performed on the patient and/or the images have been made. In practice the time is the instance on which the first image has been taken.\n* The start time the service being documented took place."
}, {
"id": "DocumentReference.context.period.end",
"path": "DocumentReference.context.period.end",
"alias": [ "VerrichtingEindDatum" ],
"short": "ProcedureEndDate / ServiceStopTime",
"mapping": [ {
"map": "bbs-dataelement-175",
"comment": "ProcedureEndDate",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-23",
"comment": "serviceStopTime",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* The end date (and if possible end time) of the procedure. A ‘vague’ date, such as only the year, is permitted.\nThe element offers the option to indicate the end of the period of a series of related procedures. The end date element is only used for a procedures that takes some time and is then always applied. If the procedure still continues, the value is left empty. For instantaneous or very short lasting procedures the element is omitted. \n* The stop time the service being documented took place."
}, {
"id": "DocumentReference.context.facilityType",
"path": "DocumentReference.context.facilityType",
"alias": [ "OrganisatieType" ],
"short": "OrganizationType / HealthcareFacilityTypeCode",
"binding": {
"strength": "extensible",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.17.2.3--20200901000000"
},
"mapping": [ {
"map": "bbs-dataelement-546",
"comment": "OrganizationType",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-31",
"comment": "healthcareFacilityTypeCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* The type of healthcare provider, such as general hospital, or nursing home. If this field is filled in and an AGB code is used for the HealthcareProviderIdentificationNumber, the type must match the type implicitly contained in the AGB code.\n* This code represents the type of organizational setting of the clinical encounter during which the documented act occurred."
}, {
"id": "DocumentReference.context.practiceSetting",
"path": "DocumentReference.context.practiceSetting",
"alias": [ "AfdelingSpecialisme" ],
"short": "DepartmentSpecialty / PracticeSettingCode ",
"binding": {
"strength": "required",
"valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.22--20240205133006"
},
"mapping": [ {
"map": "bbs-dataelement-524",
"comment": "DepartmentSpecialty",
"identity": "bbs-dataset-100-alpha2-20240208"
}, {
"map": "ihexds-dataelement-20",
"comment": "practiceSettingCode",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* The specialty of the healthcare provider’s department. The departmental specialty can be filled in if further indication of the healthcare provider is needed. This refers to the recognized medical specialties as stated in the BIG Act.\nThe bound value set is the value set that has been proposed by IHE MCWG to the EU (Xt-EHR) for national and international exchange.\n* The code specifying the clinical specialty where the act that resulted in the document was performed (e.g. Family Practice, Laboratory, Radiology). "
}, {
"id": "DocumentReference.context.sourcePatientInfo",
"path": "DocumentReference.context.sourcePatientInfo",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ]
} ],
"short": "SourcePatientId / SourcePatientInfo",
"mapping": [ {
"map": "ihexds-dataelement-25",
"comment": "sourcePatientId",
"identity": "ihexds-dataset-2024-20220712"
}, {
"map": "ihexds-dataelement-26",
"comment": "sourcePatientInfo",
"identity": "ihexds-dataset-2024-20220712"
} ],
"definition": "* The sourcePatientId represents the subject of care medical record Identifier (e.g. Patient Id) in the local patient Identifier Domain of the Document Source.\n* The sourcePatientInfo contains demographic information of the patient to whose medical record this document belongs."
}, {
"id": "DocumentReference.context.related",
"path": "DocumentReference.context.related",
"short": "ReferenceIdList",
"comment": "Encounters on the ReferenceIdList are conveyed via `.context.encounter`.",
"mapping": [ {
"map": "ihexds-dataelement-117",
"comment": "referenceIdList",
"identity": "ihexds-dataset-2024-20220712"
} ],
"slicing": {
"rules": "open",
"discriminator": [ {
"path": "identifier.type",
"type": "value"
} ]
},
"definition": "A list of identifiers that apply to the document. Identifiers may be Accession Numbers, Order Numbers, Referral Request Identifiers, XDS Workflow Instance Identifiers, etc. \n\nFor Imaging (Reports), use the Accession Number with Assigning Authority, Order Number with Assigning Authority and StudyUID, as proposed by the IHE MCWG to support linking the Images and Reports together."
}, {
"id": "DocumentReference.context.related:accessionNumber",
"max": "1",
"min": 0,
"path": "DocumentReference.context.related",
"sliceName": "accessionNumber"
}, {
"id": "DocumentReference.context.related:accessionNumber.identifier",
"min": 1,
"path": "DocumentReference.context.related.identifier",
"alias": [ "AccessionNumber" ],
"short": "AccessionNumber",
"mapping": [ {
"map": "bbs-medmij-dataelement-3",
"comment": "AccessionNumber",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"map": "bbs-medmij-dataelement-3",
"comment": "AccessionNumber",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
} ],
"definition": "A locally unique record number in the RIS that identifies the imaging procedure request."
}, {
"id": "DocumentReference.context.related:accessionNumber.identifier.type",
"min": 1,
"path": "DocumentReference.context.related.identifier.type",
"patternCodeableConcept": {
"coding": [ {
"code": "urn:ihe:iti:xds:2013:accession",
"system": "urn:ietf:rfc:3986"
} ]
}
}, {
"id": "DocumentReference.context.related:accessionNumber.identifier.system",
"min": 1,
"path": "DocumentReference.context.related.identifier.system",
"comment": "In DICOM, the Accession Number is just a string (namely of DICOM data type _Short String_ (_SH_)). In order to ensure uniqueness of the Accession Number, a `.system` SHALL be provided. It is up to the Assigning Authority that issued the Accession Number to determine and manage an appropriate URL or URN as `.system`. If no specific URL or URN for the Accession Number identifier system is provided in the source data, the identifier of the Assigning Authority itself SHOULD be used as fallback, i.e. the OID registered for the Assigning Authority, which should be present in DICOM tag `(0040,0032)` (Universal Entity ID) as part of `(0008,0051)` (Issuer of Accession Number Sequence).",
"mapping": [ {
"map": "bbs-medmij-dataelement-7",
"comment": "AssigningAuthority (implicit, main mapping is on .context.related[accessionNumber].identifier.assigner)",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
} ]
}, {
"id": "DocumentReference.context.related:accessionNumber.identifier.value",
"min": 1,
"path": "DocumentReference.context.related.identifier.value"
}, {
"id": "DocumentReference.context.related:accessionNumber.identifier.assigner",
"path": "DocumentReference.context.related.identifier.assigner",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ]
} ],
"alias": [ "UitgevendeInstantie" ],
"short": "AssigningAuthority",
"mapping": [ {
"map": "bbs-medmij-dataelement-7",
"comment": "AssigningAuthority",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
} ],
"definition": "Assigning authority that issued the Accession Number."
}, {
"id": "DocumentReference.context.related:studyInstanceUID",
"max": "1",
"min": 0,
"path": "DocumentReference.context.related",
"sliceName": "studyInstanceUID"
}, {
"id": "DocumentReference.context.related:studyInstanceUID.identifier",
"min": 1,
"path": "DocumentReference.context.related.identifier",
"alias": [ "StudyInstanceUID" ],
"short": "StudyInstanceUID",
"mapping": [ {
"map": "bbs-medmij-dataelement-4",
"comment": "StudyInstanceUID",
"identity": "bbs-medmij-dataset-100-beta1-20250807"
}, {
"map": "bbs-medmij-dataelement-4",
"comment": "StudyInstanceUID",
"identity": "bbs-medmij-dataset-100-rc1-20250919"
} ],
"definition": "The globally unique DICOM identifier of the imaging study upon which the imaging report is based, assigned by the modality or PACS."
}, {
"id": "DocumentReference.context.related:studyInstanceUID.identifier.type",
"min": 1,
"path": "DocumentReference.context.related.identifier.type",
"patternCodeableConcept": {
"coding": [ {
"code": "urn:ihe:iti:xds:2016:studyInstanceUID",
"system": "urn:ietf:rfc:3986"
} ]
}
}, {
"id": "DocumentReference.context.related:studyInstanceUID.identifier.system",
"min": 1,
"path": "DocumentReference.context.related.identifier.system",
"patternUri": "urn:dicom:uid"
}, {
"id": "DocumentReference.context.related:studyInstanceUID.identifier.value",
"min": 1,
"path": "DocumentReference.context.related.identifier.value",
"comment": "As the Study Instance UID is a DICOM UID, its value SHALL be prefixed with _urn:oid:_.",
"constraint": [ {
"key": "bbs-DocumentReference-3",
"human": "Each DICOM UID value is a proper OID.",
"source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference",
"severity": "error",
"expression": "$this.startsWith('urn:oid:')"
} ]
} ]
},
"contact": [ {
"name": "MedMij",
"telecom": [ {
"use": "work",
"value": "info@medmij.nl",
"system": "email"
} ]
} ],
"baseDefinition": "https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.UnContained.Comprehensive.DocumentReference"
}