FHIR Release 3 (STU) Current Build
This page is part of FHIR STU 3 (v3.0.1) in it's permanent home (it will always be available at this URL). It has been superceded by R4 . For a full list of available versions, see the Directory of published versions .
Structured Documents Orders and Observations Work Group Maturity Level : N/A Ballot Standards Status : Informative Security Category : Not Classified Compartments : Device , Encounter , Patient , Practitioner , RelatedPerson

Mappings for the documentreference resource. resource (see Mappings to Other Standards for further information & status).

DocumentReference
    masterIdentifier FiveWs.identifier
    identifier FiveWs.identifier
    status FiveWs.status
    docStatus FiveWs.status
    type FiveWs.what[x]
    category FiveWs.what[x]
    subject FiveWs.subject[x]
    date FiveWs.recorded
    authenticator FiveWs.witness
        encounter FiveWs.context
DocumentReference Event
    masterIdentifier Event.identifier
    identifier Event.identifier
    status Event.status
    type Event.code
    subject Event.subject
    date Event.occurrence[x]
    author Event.performer.actor
    authenticator Event.performer.actor
    custodian Event.performer.actor
        encounter Event.context
DocumentReference
    masterIdentifier TXA-12
    identifier TXA-16?
    status TXA-19
    docStatus TXA-17
    type TXA-2
    category
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
    date
    author TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
    authenticator TXA-10
    custodian
    relatesTo
        code
        target
    description TXA-25
    securityLabel TXA-18
    content
        attachment TXA-3 for mime type
        format
    context
        encounter
        event
        period
        facilityType
        practiceSetting
        sourcePatientInfo
        related
        basedOn
DocumentReference when describing a CDA
    masterIdentifier ClinicalDocument/id
    identifier
    status
    docStatus
    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/
    date
    author ClinicalDocument/author
    authenticator ClinicalDocument/legalAuthenticator
    custodian
    relatesTo
        code
        target
    description
    securityLabel ClinicalDocument/confidentialityCode/@code
    content
        attachment ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
        format derived from the IHE Profile or Implementation Guide templateID
    context
        encounter
        event
        period ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/low/
@value --> ClinicalDocument/documentationOf/
serviceEvent/effectiveTime/high/
@value
        facilityType usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
        practiceSetting usually from a mapping to a local ValueSet
        sourcePatientInfo ClinicalDocument/recordTarget/
        related ClinicalDocument/relatedDocument
        basedOn
DocumentReference Document[classCode="DOC" and moodCode="EVN"]
    masterIdentifier .id
    identifier .id / .setId
    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
    class     category .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
    subject .participation[typeCode="SBJ"].role[typeCode="PAT"]
    created .effectiveTime[type="TS"]     indexed     date .availabilityTime[type="TS"]
    author .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
    authenticator .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
    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
        format document.text
    context outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
        encounter unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
        event .code
        period .effectiveTime
        facilityType .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        practiceSetting .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
        sourcePatientInfo .participation[typeCode="SBJ"].role[typeCode="PAT"]
        related ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
            identifier ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] .id             ref ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct].text.reference         basedOn .outboundRelationship[typeCode=FLFS].target
DocumentReference
    masterIdentifier TXA-12 DocumentEntry.uniqueId
    identifier TXA-16? DocumentEntry.entryUUID
    status TXA-19 DocumentEntry.availabilityStatus
    docStatus TXA-17
    type TXA-2 DocumentEntry.typeCode
    class     category DocumentEntry.classCode
    subject PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)     created TXA-6 DocumentEntry.patientId
    indexed     date
    author TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message) DocumentEntry.author
    authenticator TXA-10 DocumentEntry.legalAuthenticator
    custodian
    relatesTo DocumentEntry Associations
        code DocumentEntry Associations type
        target DocumentEntry Associations reference
    description TXA-25 DocumentEntry.comments
    securityLabel TXA-18 DocumentEntry.confidentialityCode
    content
        attachment TXA-3 for mime type DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
        format DocumentEntry.formatCode
    context
        encounter
        event DocumentEntry.eventCodeList
        period DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
        facilityType DocumentEntry.healthcareFacilityTypeCode
        practiceSetting DocumentEntry.practiceSettingCode
        sourcePatientInfo DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
        related             identifier DocumentEntry.referenceIdList
            ref         basedOn DocumentEntry.referenceIdList
DocumentReference when describing a Composition
    masterIdentifier DocumentEntry.uniqueId Composition.identifier
    identifier DocumentEntry.entryUUID
    status DocumentEntry status
    docStatus Composition.status
    type DocumentEntry.type Composition.type
    class     category DocumentEntry.class Composition.class
    subject DocumentEntry.patientId     created DocumentEntry.submissionTime Composition.subject
    indexed     date DocumentEntry.submissionTime Composition.date
    author DocumentEntry.author Composition.author
    authenticator DocumentEntry.legalAuthenticator Composition.attester
    custodian Composition.custodian
    relatesTo Composition.relatesTo
        code DocumentEntry Associations type Composition.relatesTo.code
        target DocumentEntry Associations reference Composition.relatesTo.target
    description DocumentEntry.description
    securityLabel DocumentEntry.confidentialityCode Composition.confidentiality, Composition.meta.security
    content Bundle(Composition+*)
        attachment DocumentEntry.mimeType DocumentEntry.languageCode DocumentEntry.URI DocumentEntry.size DocumentEntry.hash DocumentEntry.title Composition.language,
Composition.title,
Composition.date
        format DocumentEntry.formatCode Composition.meta.profile
    context
        encounter Composition.encounter
        event DocumentEntry.eventCodeList Composition.event.code
        period DocumentEntry.serviceStartTime DocumentEntry.serviceStopTime Composition.event.period
        facilityType DocumentEntry.healthcareFacilityTypeCode usually from a mapping to a local ValueSet
        practiceSetting DocumentEntry.practiceSettingCode usually from a mapping to a local ValueSet
        sourcePatientInfo DocumentEntry.sourcePatientInfo DocumentEntry.sourcePatientId Composition.subject
        related DocumentEntry.referenceIdList             identifier Composition.event.detail
            ref         basedOn