US Veterans Health Administration FHIR Map Set Implementation Guide
1.3.1 - 250401
US Veterans Health Administration FHIR Map Set Implementation Guide
1.3.1 - 250401
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| Active as of 2025-03-31 |
Mappings for the DiagnosticReportNoteSurgicalPathologyDiagnosticReport resource profile.
Scroll down for the Raw FHIR, CDW & SDA mappings (if any).
Note that the CDW and SDA mappings are derived from a look-up based on the VistA source mappings in CDW and VPR SDA.
| key | status | direction | source | mapApproach | mapCase | FHIR Path | subPath | mapValue | mapParameter | mapComment | FHIR URL | Ver |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1606 | for review | V2F | SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - IEN (63.08-.35 > 63.53-.001) | source value | DiagnosticReport.identifier | .value | .system = http://va.gov/identifiers/$Sta3n/63.53 | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||
| 1606-1 | for review | V2F | fixed value | DiagnosticReport.identifier | .system | http://va.gov/identifiers/$Sta3n/63.53 | generated from mapParameter line 1 | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||
| 1691 | for review | V2F | SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - CPRS ORDER # (63.08-.35 > 63.53-3) | reference | DiagnosticReport.basedOn | http://hl7.org/fhir/StructureDefinition/ServiceRequest | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1809 | for review | V2F | SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - NAME (63.08-.16 > 63.19-1 > 8925-.01 > 8925.1-.01) | source value | DiagnosticReport.code | .text | Per KBS discussion, this value should be Local Title + Specimen.type.text. The local title is this map row; Specimen.type.text is key 1703. | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||
| 1810 | for review | V2F | fixed value | DiagnosticReport.code | http://loinc.org#27898-6 "Pathology studies (set)" | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||||
| 1811 | for review | V2F | SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - VHA ENTERPRISE STANDARD TITLE > TIU VHA ENTERPRISE STANDARD TITLE - CODING SYSTEM > CODING SYSTEM - CODE > CODE - CODE (63.08-.16 > 63.19-1 > 8925-.01 > 8925.1-1501 > 8926.1-2 > 8926.12-.02 > 8926.121-.01) | source value | DiagnosticReport.code.coding | .code | .system=http://loinc.org | Made inactive but reactivated; after reviewing discussion with KBST from 4/25/2024 this should be included with the fixed value as it's the "standardized title" in TIU. See LEAF 90. Include if not null and include in addition to the fixed .code value. | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||
| 1811-1 | for review | V2F | fixed value | DiagnosticReport.code.coding | .system | http://loinc.org | generated from mapParameter line 1 | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||
| 1417 | for review | V2F | SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - DISPOSITION (63.08-.35 > 63.53-10) | terminologyMaps | DiagnosticReport.status | VF_DiagnosticReportLabStatus | US Core 5 has new constraints: if status is partial, preliminary, final, ammended, corrected or appended effective[x] and issued are required | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||
| 2206 | for review | V2F | fixed value | DiagnosticReport.category | http://loinc.org#LP7839-6 "Pathology" | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||||
| 2212 | for review | V2F | PATIENT - LABORATORY REFERENCE > LAB DATA - LRDFN (2-63 > 63-.01) | reference | DiagnosticReport.subject | /Patient | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 2207 | for review | V2F | SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - CPRS ORDER # > ORDER - ORDER # < TEST - PCE VISIT # (63.08-.35 > 63.53-3>100-.01<69.03-12) | reference | DiagnosticReport.encounter | /EncounterOutpatient | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1425 | for review | V2F | SURGICAL PATHOLOGY - DATE/TIME SPECIMEN TAKEN (63.08-.01) | source value | DiagnosticReport.effectiveDateTime | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||||
| 1430 | for review | V2F | SURGICAL PATHOLOGY - DATE REPORT COMPLETED (63.08-.03) | source value | DiagnosticReport.issued | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | |||||
| 1435 | for review | V2F | SURGICAL PATHOLOGY - RELEASED BY (63.08-.13) | reference | DiagnosticReport.performer[va-by] | /Practitioner | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1686 | for review | V2F | SURGICAL PATHOLOGY - RELEASING SITE (63.08-.345) | reference | DiagnosticReport.performer[va-at] | /Organization | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1700 | for review | V2F | SURGICAL PATHOLOGY - PATHOLOGIST (63.08-.02) | reference | DiagnosticReport.resultsInterpreter | /Practitioner | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1701 | for review | V2F | SURGICAL PATHOLOGY - SURGICAL PATH ACC # (63.08-.06) | reference | DiagnosticReport.specimen | Specimen | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1439 | for review | V2F | SURGICAL PATHOLOGY - IMAGE (63.08-2005) | reference | DiagnosticReport.media.link | More information about the image may be available if stakeholders identify requirements. | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1447 | for review | V2F | SURGICAL PATHOLOGY - SURGICAL PATH DIAGNOSIS (63.08-1.4) | source value | DiagnosticReport.conclusion | Vista field is word processing so CodeableConcept cannot be used | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 | ||||
| 1721 | for review | V2F | SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - REPORT TEXT (63.08-.16 > 63.19-1 > 8925-2) | source value | DiagnosticReport.presentedForm | .data | HDR may be used to get the report | http://hl7.org/fhir/us/core/StructureDefinition/us-core-diagnosticreport-note | 5.0.1 |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | ||
| identifier | ||
| system | 1606-1: fixed value = http://va.gov/identifiers/$Sta3n/63.53 | generated from mapParameter line 1 |
| value | 1606: source value based on SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - IEN (63.08-.35 > 63.53-.001) | |
| basedOn | 1691: reference based on SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - CPRS ORDER # (63.08-.35 > 63.53-3) | |
| status | 1417: terminologyMaps using VF_DiagnosticReportLabStatus on SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - DISPOSITION (63.08-.35 > 63.53-10) | US Core 5 has new constraints: if status is partial, preliminary, final, ammended, corrected or appended effective[x] and issued are required |
| category | 2206: fixed value = http://loinc.org#LP7839-6 "Pathology" | |
| code | 1810: fixed value = http://loinc.org#27898-6 "Pathology studies (set)" | |
| coding | ||
| system | 1811-1: fixed value = http://loinc.org | generated from mapParameter line 1 |
| code | 1811: source value based on SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - VHA ENTERPRISE STANDARD TITLE > TIU VHA ENTERPRISE STANDARD TITLE - CODING SYSTEM > CODING SYSTEM - CODE > CODE - CODE (63.08-.16 > 63.19-1 > 8925-.01 > 8925.1-1501 > 8926.1-2 > 8926.12-.02 > 8926.121-.01) | Made inactive but reactivated; after reviewing discussion with KBST from 4/25/2024 this should be included with the fixed value as it's the "standardized title" in TIU. See LEAF 90. Include if not null and include in addition to the fixed .code value. |
| text | 1809: source value based on SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - NAME (63.08-.16 > 63.19-1 > 8925-.01 > 8925.1-.01) | Per KBS discussion, this value should be Local Title + Specimen.type.text. The local title is this map row; Specimen.type.text is key 1703. |
| subject | 2212: reference based on PATIENT - LABORATORY REFERENCE > LAB DATA - LRDFN (2-63 > 63-.01) | |
| encounter | 2207: reference based on SURGICAL PATHOLOGY - ORDERED TEST > ORDERED TEST - CPRS ORDER # > ORDER - ORDER # < TEST - PCE VISIT # (63.08-.35 > 63.53-3>100-.01<69.03-12) | |
| effective[x] (effectiveDateTime) | 1425: source value based on SURGICAL PATHOLOGY - DATE/TIME SPECIMEN TAKEN (63.08-.01) | |
| issued | 1430: source value based on SURGICAL PATHOLOGY - DATE REPORT COMPLETED (63.08-.03) | |
| performer (va-by) | 1435: reference based on SURGICAL PATHOLOGY - RELEASED BY (63.08-.13) | |
| performer (va-at) | 1686: reference based on SURGICAL PATHOLOGY - RELEASING SITE (63.08-.345) | |
| resultsInterpreter | 1700: reference based on SURGICAL PATHOLOGY - PATHOLOGIST (63.08-.02) | |
| specimen | 1701: reference based on SURGICAL PATHOLOGY - SURGICAL PATH ACC # (63.08-.06) | |
| media | ||
| link | 1439: reference based on SURGICAL PATHOLOGY - IMAGE (63.08-2005) | More information about the image may be available if stakeholders identify requirements. |
| conclusion | 1447: source value based on SURGICAL PATHOLOGY - SURGICAL PATH DIAGNOSIS (63.08-1.4) | Vista field is word processing so CodeableConcept cannot be used |
| presentedForm | ||
| data | 1721: source value based on SURGICAL PATHOLOGY - TIU REFERENCE DATE/TIME - SP > TIU REFERENCE DATE/TIME - SP - TIU ENTRY POINTER - SP > TIU DOCUMENT - REPORT TEXT (63.08-.16 > 63.19-1 > 8925-2) | HDR may be used to get the report |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | ||
| basedOn | Pathology.SurgPathOrderedTest.CPRSOrderIEN,Pathology.SurgPathOrderedTest.CPRSOrderSID | |
| status | Pathology.SurgPathOrderedTest.DispositionLabCodeIEN,Pathology.SurgPathOrderedTest.DispositionLabCodeSID | |
| subject | Micro.AntibioticSensitivity.LRDFN,Micro.AntibioticSensitivityComment.LRDFN,Micro.BacteriologyReports.LRDFN,Micro.MicroAntibioticLevel.LRDFN,Micro.MicroAudit.LRDFN,Micro.Microbiology.LRDFN,Micro.MicroOrderedTest.LRDFN,Micro.MicroSterilityResults.LRDFN,Micro.MycobacteriologyReports.LRDFN,Micro.Mycology.LRDFN,Micro.MycologyReports.LRDFN,Micro.Parasitology.LRDFN,Micro.ParasitologyReports.LRDFN,Micro.ParasitologyStage.LRDFN,Micro.Virology.LRDFN,Micro.VirologyReports.LRDFN,Pathology.Autopsy.LRDFN,Pathology.CytoOrganTissueFunction.StaffIEN,SStaff.SMicroOrderedTest.LRDFN | |
| effective[x] (effectiveDateTime) | Pathology.SurgicalPathology.SpecimenTakenDateTime,Pathology.SurgPathComment.SpecimenTakenDateTime,Pathology.SurgPathDelayedComment.SpecimenTakenDateTime,Pathology.SurgPathDiagnosis.SpecimenTakenDateTime,Pathology.SurgPathFrozenSection.SpecimenTakenDateTime,Pathology.SurgPathGrossDescription.SpecimenTakenDateTime,Pathology.SurgPathMicroscopicExam.SpecimenTakenDateTime,Pathology.SurgPathOpFindings.SpecimenTakenDateTime,Pathology.SurgPathOrderedTest.SpecimenTakenDateTime,Pathology.SurgPathOrganTissueDisease.SpecimenTakenDateTime,Pathology.SurgPathOrganTissueEtiology.SpecimenTakenDateTime,Pathology.SurgPathOrganTissueFunction.SpecimenTakenDateTime,Pathology.SurgPathOrganTissueMorphology.SpecimenTakenDateTime,Pathology.SurgPathOrganTissueProcedure.SpecimenTakenDateTime,Pathology.SurgPathPostOpDiagnosis.SpecimenTakenDateTime,Pathology.SurgPathPreOpDiagnosis.SpecimenTakenDateTime,Pathology.SurgPathSpecimen.SpecimenTakenDateTime,Pathology.SurgPathSupplement.SpecimenTakenDateTime,Pathology.SurgPathSupplementDescript.SpecimenTakenDateTime,Pathology.SurgPathTIUReference.SpecimenTakenDateTime | |
| issued | Pathology.SurgicalPathology.ReportCompletedDateTime | |
| performer (va-by) | Pathology.SurgicalPathology.ReleasedByStaffIEN | |
| performer (va-at) | Pathology.SurgicalPathology.ReleasingInstitutionIEN | |
| resultsInterpreter | Pathology.SurgicalPathology.PathologistStaffIEN | |
| specimen | Pathology.SurgicalPathology.SurgicalPathologyShortAccessionNumber | |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | ||
| subject | Patient.Extension[PatientExtension].VeteranLrdfn | |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | Event | |
| identifier | Event.identifier | |
| basedOn | Event.basedOn | |
| status | Event.status | |
| code | Event.code | |
| subject | Event.subject | |
| encounter | Event.encounter | |
| effective[x] | Event.occurrence[x] | |
| effective[x] (effectiveDateTime) | Event.occurrence[x] | |
| performer | Event.performer.actor | |
| performer (va-by) | Event.performer.actor | |
| performer (va-at) | Event.performer.actor | |
| resultsInterpreter | Event.performer.actor | |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | ORU -> OBR | |
| identifier | OBR-51/ for globally unique filler ID - OBR-3 , For non-globally unique filler-id the flller/placer number must be combined with the universal service Id - OBR-2(if present)+OBR-3+OBR-4 | |
| use | N/A | |
| type | CX.5 | |
| system | CX.4 / EI-2-4 | |
| value | CX.1 / EI.1 | |
| period | CX.7 + CX.8 | |
| assigner | CX.4 / (CX.4,CX.9,CX.10) | |
| basedOn | ORC? OBR-2/3? | |
| status | OBR-25 (not 1:1 mapping) | |
| category | OBR-24 | |
| category (us-core) | OBR-24 | |
| code | OBR-4 (HL7 v2 doesn't provide an easy way to indicate both the ordered test and the performed panel) | |
| coding | C*E.1-8, C*E.10-22 | |
| system | C*E.3 | |
| version | C*E.7 | |
| code | C*E.1 | |
| display | C*E.2 - but note this is not well followed | |
| userSelected | Sometimes implied by being first | |
| text | C*E.9. But note many systems use C*E.2 for this | |
| subject | PID-3 (no HL7 v2 mapping for Group or Device) | |
| encounter | PV1-19 | |
| effective[x] | OBR-7 | |
| effective[x] (effectiveDateTime) | OBR-7 | |
| issued | OBR-22 | |
| performer | PRT-8 (where this PRT-4-Participation = "PO") | |
| performer (va-by) | PRT-8 (where this PRT-4-Participation = "PO") | |
| performer (va-at) | PRT-8 (where this PRT-4-Participation = "PO") | |
| resultsInterpreter | OBR-32, PRT-8 (where this PRT-4-Participation = "PI") | |
| specimen | SPM | |
| result | OBXs | |
| media | OBX? | |
| conclusion | OBX | |
| conclusionCode | OBX | |
| presentedForm | OBX | |
| contentType | ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used | |
| data | ED.5 | |
| url | RP.1+RP.2 - if they refer to a URL (see v2.6) | |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | Entity. Role, or Act, Observation[classCode=OBS, moodCode=EVN] | |
| text | Act.text? | |
| contained | N/A | |
| extension | N/A | |
| modifierExtension | N/A | |
| identifier | id | |
| id | n/a | |
| extension | n/a | |
| use | Role.code or implied by context | |
| type | Role.code or implied by context | |
| system | II.root or Role.id.root | |
| value | II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root) | |
| period | Role.effectiveTime or implied by context | |
| assigner | II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper | |
| basedOn | outboundRelationship[typeCode=FLFS].target | |
| status | statusCode Note: final and amended are distinguished by whether observation is the subject of a ControlAct event of type "revise" | |
| category | inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code | |
| category (us-core) | inboundRelationship[typeCode=COMP].source[classCode=LIST, moodCode=EVN, code < LabService].code | |
| code | code | |
| id | n/a | |
| extension | n/a | |
| coding | union(., ./translation) | |
| id | n/a | |
| extension | n/a | |
| system | ./codeSystem | |
| version | ./codeSystemVersion | |
| code | ./code | |
| display | CV.displayName | |
| userSelected | CD.codingRationale | |
| text | ./originalText[mediaType/code="text/plain"]/data | |
| subject | participation[typeCode=SBJ] | |
| encounter | inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN] | |
| effective[x] | effectiveTime | |
| effective[x] (effectiveDateTime) | effectiveTime | |
| issued | participation[typeCode=VRF or AUT].time | |
| performer | .participation[typeCode=PRF] | |
| performer (va-by) | .participation[typeCode=PRF] | |
| performer (va-at) | .participation[typeCode=PRF] | |
| resultsInterpreter | .participation[typeCode=PRF] | |
| specimen | participation[typeCode=SBJ] | |
| result | outboundRelationship[typeCode=COMP].target | |
| imagingStudy | outboundRelationship[typeCode=COMP].target[classsCode=DGIMG, moodCode=EVN] | |
| media | outboundRelationship[typeCode=COMP].target | |
| id | n/a | |
| extension | n/a | |
| modifierExtension | N/A | |
| comment | .inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="annotation"].value | |
| link | .value.reference | |
| conclusion | inboundRelationship[typeCode="SPRT"].source[classCode=OBS, moodCode=EVN, code=LOINC:48767-8].value (type=ST) | |
| conclusionCode | inboundRelationship[typeCode=SPRT].source[classCode=OBS, moodCode=EVN, code=LOINC:54531-9].value (type=CD) | |
| presentedForm | text (type=ED) | |
| id | n/a | |
| extension | n/a | |
| contentType | ./mediaType, ./charset | |
| language | ./language | |
| data | ./data | |
| url | ./reference/literal | |
| size | N/A (needs data type R3 proposal) | |
| hash | .integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"] | |
| title | ./title/data | |
| creation | N/A (needs data type R3 proposal) | |
| DiagnosticReportNoteSurgicalPathologyDiagnosticReport | ||
| DiagnosticReport | ||
| identifier | FiveWs.identifier | |
| status | FiveWs.status | |
| category | FiveWs.class | |
| category (us-core) | FiveWs.class | |
| code | FiveWs.what[x] | |
| subject | FiveWs.subject[x], FiveWs.subject | |
| encounter | FiveWs.context | |
| effective[x] | FiveWs.done[x] | |
| effective[x] (effectiveDateTime) | FiveWs.done[x] | |
| issued | FiveWs.recorded | |
| performer | FiveWs.actor | |
| performer (va-by) | FiveWs.actor | |
| performer (va-at) | FiveWs.actor | |
| resultsInterpreter | FiveWs.actor | |