US Veterans Health Administration FHIR Map Set Implementation Guide
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Resource Profile: DocumentReferenceDocumentReference - Mappings

Active as of 2025-06-20

Mappings for the DocumentReferenceDocumentReference resource profile.

Scroll down for the Raw FHIR, CDW & SDA mappings (if any).

Note that the CDW, SDA and VPR XML mappings are derived from a look-up based on the VistA source.

Mapping Sources

Use Case: Document Reference (Source)Use Case: Document Reference (Source)HOSPITAL LOCATION (44)2TYPETIU DOCUMENT (8925).001IEN.01DOCUMENT TYPE.02PATIENT.03VISIT.07EPISODE BEGIN DATE/TIME.08EPISODE END DATE/TIME.13VISIT TYPE2REPORT TEXT1201ENTRY DATE/TIME1202AUTHOR/DICTATOR1205HOSPITAL LOCATION1212DIVISION1306VERIFIED BY1402TREATING SPECIALTY1502SIGNED BY1701SUBJECT (OPTIONAL description)PATIENT/IHS (9000001).01NAMETIU DOCUMENT DEFINITION (8925.1)1501VHA ENTERPRISE STANDARD TITLETIU VHA ENTERPRISE STANDARD TITLE (8926.1).01STANDARD TITLE.08DOCUMENT TYPE2CODING SYSTEM

Raw Mappings

key status direction source mapApproach mapCase FHIR Path subPath mapValue mapParameter mapComment FHIR URL | Ver
870 team-approved V2F target not supported DocumentReference.masterIdentifier Not Must Support http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
871 team-approved V2F TIU DOCUMENT - IEN (8925-.001) source value DocumentReference.identifier .system = http://va.gov/identifiers/$Sta3n/8925 http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
874 team-approved V2F TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - VHA ENTERPRISE STANDARD TITLE > TIU VHA ENTERPRISE STANDARD TITLE (8925-.01 > 8925.1-1501 > 8926.1) source value DocumentReference.type .coding.system=http://loinc.org
.coding.code={CODING SYSTEM(2)}
.text={DOCUMENT TYPE(.08)}
Get LOINC from VistA or use TIU_VHA_ENTERPRISE_STANDARD_TITLE_8926.1 file provided by KBS to look up LOINC mapping CDW now has a view. N.B. CODING SYSTEM(2) is always LOINC codes! http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
875 for review V2F fixed value DocumentReference.category[us-core] http://hl7.org/fhir/us/core/CodeSystem/us-core-documentreference-category#clinical-note (= NOTE, ADDENDUM, CONSULT, etc.?) Use TIU_VHA_ENTERPRISE_STANDARD_TITLE_8926.1 file provided by KBS to look up DocType If the document has a type or parent value, use that for the category http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
876 team-approved V2F TIU DOCUMENT - PATIENT > PATIENT/IHS - NAME (8925-.02 > 9000001-.01) reference DocumentReference.subject /Patient Pointer to PATIENT/HIS FILE (#9000001) http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
877 team-approved V2F transform DocumentReference.date Resource_creation_time() looking into façade pattern guidance on whether this is meaningful. 03/6/23 updated mapping based on LHV feedback http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
878 team-approved V2F TIU DOCUMENT - AUTHOR/DICTATOR (8925-1202) reference DocumentReference.author /Practitioner http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
1663 for review V2F TIU DOCUMENT - SIGNED BY (8925-1502) reference DocumentReference.author /Practitioner Added signed by as an author since it allows more than one. http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
879 team-approved V2F TIU DOCUMENT - VERIFIED BY (8925-1306) reference DocumentReference.authenticator /Practitioner http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
880 team-approved V2F TIU DOCUMENT - DIVISION (8925-1212) reference DocumentReference.custodian /Organization who maintains the document = VA…. Or maybe a specific? Clinic Per 03/02/2023 email from LH, changed the Vista field from 1205 (hospital location) to 1212 (division). http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
885 team-approved V2F TIU DOCUMENT - SUBJECT (OPTIONAL description) (8925-1701) source value DocumentReference.description http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
886 team-approved V2F target not supported DocumentReference.securityLabel http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
887 team-approved V2F target not supported DocumentReference.content.id remove http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
888 team-approved V2F TIU DOCUMENT - IEN (8925-.001) source value DocumentReference.content.attachment.id keep. Using HDR to pull text; need this http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
889 team-approved V2F fixed value DocumentReference.content.attachment.contentType #text/plain http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
890 team-approved V2F target not supported DocumentReference.content.attachment.language http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
892 team-approved V2F TIU DOCUMENT - REPORT TEXT (8925-2) transform DocumentReference.content.attachment.url create(Binary) option 2: USED in PHAPI US Core: DocumentReference.content.attachment.url or DocumentReference.content.attachment.data or both SHALL be present. http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
893 team-approved V2F TIU DOCUMENT - REPORT TEXT (8925-2) transform DocumentReference.content.attachment.size calculate() http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
894 team-approved V2F TIU DOCUMENT - REPORT TEXT (8925-2) transform DocumentReference.content.attachment.hash calculate() http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
895 team-approved V2F TIU DOCUMENT - DOCUMENT TYPE > TIU DOCUMENT DEFINITION - VHA ENTERPRISE STANDARD TITLE > TIU VHA ENTERPRISE STANDARD TITLE - STANDARD TITLE (8925-.01 > 8925.1-1501 > 8926.1-.01) source value DocumentReference.content.attachment.title 03/06/23 added the secondary subfield based on LH feedback http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
896 team-approved V2F TIU DOCUMENT - ENTRY DATE/TIME (8925-1201) source value DocumentReference.content.attachment.creation .07 does not indicate parent or child document only the treatment episode associated with document http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
897 team-approved V2F target not supported DocumentReference.content.format These are specific document types, mostly IHE, not MIME http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
898 team-approved V2F target not supported DocumentReference.context.id Or ad hoc, for transient assets http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
899 team-approved V2F TIU DOCUMENT - VISIT (8925-.03) reference DocumentReference.context.encounter http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
900 team-approved V2F TIU DOCUMENT - VISIT TYPE (8925-.13) source value DocumentReference.context.event candidate: 8925-.13 http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
901 team-approved V2F TIU DOCUMENT - EPISODE BEGIN DATE/TIME (8925-.07) source value DocumentReference.context.period .start http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
902 team-approved V2F TIU DOCUMENT - EPISODE END DATE/TIME (8925-.08) source value DocumentReference.context.period .end http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
903 team-approved V2F TIU DOCUMENT - HOSPITAL LOCATION > HOSPITAL LOCATION - TYPE (8925-1205 > 44-2) source value DocumentReference.context.facilityType http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
904 team-approved V2F TIU DOCUMENT - TREATING SPECIALTY (8925-1402) source value DocumentReference.context.practiceSetting http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
905 team-approved V2F target not supported DocumentReference.context.sourcePatientInfo a snapshot of patient at time of document http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1
906 team-approved V2F target not supported DocumentReference.context.related other related assets http://hl7.org/fhir/us/core/StructureDefinition/us-core-documentreference | 5.0.1

Mappings to Structures in this Implementation Guide

No Mappings Found

Mappings to other Structures

No Mappings Found

Other Mappings

NameWorkflow PatternFHIR CompositionRIM MappingCDA (R2)FiveWs Pattern MappingHL7 v2 MappingXDS metadata equivalentdoco
.. DocumentReference
Event
when describing a Composition
Document[classCode="DOC" and moodCode="EVN"]
when describing a CDA
... id
... meta
... implicitRules
... text
Act.text?
... contained
N/A
... extension
N/A
... modifierExtension
N/A
... masterIdentifier
Event.identifier
Composition.identifier
.id
ClinicalDocument/id
FiveWs.identifier
TXA-12
DocumentEntry.uniqueId
... identifier
Event.identifier
.id / .setId
FiveWs.identifier
TXA-16?
DocumentEntry.entryUUID
.... id
n/a
.... extension
n/a
.... use
Role.code or implied by context
N/A
.... type
Role.code or implied by context
CX.5
.... system
II.root or Role.id.root
CX.4 / EI-2-4
.... value
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
CX.1 / EI.1
.... period
Role.effectiveTime or implied by context
CX.7 + CX.8
.... assigner
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
  • CX.4 / (CX.4
  • CX.9
  • CX.10)
... status
Event.status
  • .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"
  • .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument"
  • .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
FiveWs.status
TXA-19
DocumentEntry.availabilityStatus
... docStatus
Composition.status
.statusCode
FiveWs.status
TXA-17
... type
Event.code
Composition.type
./code
  • 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.
FiveWs.class
TXA-2
DocumentEntry.type
.... id
n/a
.... extension
n/a
.... coding
  • union(.
  • ./translation)
  • C*E.1-8
  • C*E.10-22
..... id
n/a
..... extension
n/a
..... system
./codeSystem
C*E.3
..... version
./codeSystemVersion
C*E.7
..... code
./code
C*E.1
..... display
CV.displayName
C*E.2 - but note this is not well followed
..... userSelected
CD.codingRationale
Sometimes implied by being first
.... text
./originalText[mediaType/code="text/plain"]/data
C*E.9. But note many systems use C*E.2 for this
... Slices for category
Composition.class
  • .outboundRelationship[typeCode="COMP].target[classCode="LIST"
  • moodCode="EVN"].code
  • 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
FiveWs.class
DocumentEntry.class
.... category:us-core
Composition.class
  • .outboundRelationship[typeCode="COMP].target[classCode="LIST"
  • moodCode="EVN"].code
  • 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
FiveWs.class
DocumentEntry.class
... subject
Event.subject
Composition.subject
.participation[typeCode="SBJ"].role[typeCode="PAT"]
ClinicalDocument/recordTarget/
FiveWs.subject
PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
DocumentEntry.patientId
... date
Event.occurrence[x]
Composition.date
.availabilityTime[type="TS"]
FiveWs.recorded
... author
Event.performer.actor
Composition.author
.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
ClinicalDocument/author
TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
DocumentEntry.author
... authenticator
Event.performer.actor
Composition.attester
.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
ClinicalDocument/legalAuthenticator
FiveWs.witness
TXA-10
DocumentEntry.legalAuthenticator
... custodian
Event.performer.actor
Composition.custodian
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
... relatesTo
Composition.relatesTo
.outboundRelationship
DocumentEntry Associations
.... id
n/a
.... extension
n/a
.... modifierExtension
N/A
.... code
Composition.relatesTo.code
.outboundRelationship.typeCode
DocumentEntry Associations type
.... target
Composition.relatesTo.target
  • .target[classCode="DOC"
  • moodCode="EVN"].id
DocumentEntry Associations reference
... description
.outboundRelationship[typeCode="SUBJ"].target.text
TXA-25
DocumentEntry.comments
... securityLabel
  • Composition.confidentiality
  • Composition.meta.security
.confidentialityCode
ClinicalDocument/confidentialityCode/@code
TXA-18
DocumentEntry.confidentialityCode
... content
Bundle(Composition+*)
document.text
.... id
n/a
.... extension
n/a
.... modifierExtension
N/A
.... attachment
  • Composition.language
  • Composition.title
  • Composition.date
document.text
  • ClinicalDocument/languageCode
  • ClinicalDocument/title
  • ClinicalDocument/date
TXA-3 for mime type
  • DocumentEntry.mimeType
  • DocumentEntry.languageCode
  • DocumentEntry.URI
  • DocumentEntry.size
  • DocumentEntry.hash
  • DocumentEntry.title
  • DocumentEntry.creationTime
..... id
n/a
..... extension
n/a
..... contentType
  • ./mediaType
  • ./charset
ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
..... language
./language
..... data
./data
ED.5
..... url
./reference/literal
RP.1+RP.2 - if they refer to a URL (see v2.6)
..... size
N/A (needs data type R3 proposal)
..... hash
:ED/integrityCheckAlgorithm="SHA-1"]
..... title
./title/data
..... creation
N/A (needs data type R3 proposal)
.... format
Composition.meta.profile
document.text
derived from the IHE Profile or Implementation Guide templateID
DocumentEntry.formatCode
... context
outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
.... id
n/a
.... extension
n/a
.... modifierExtension
N/A
.... encounter
Event.context
Composition.encounter
  • unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]
  • priorityNumber)/target[moodCode="EVN" and classCode=("ENC"
  • "PCPR") and isNormalAct])
FiveWs.context
.... event
Composition.event.code
.code
DocumentEntry.eventCodeList
.... period
Composition.event.period
.effectiveTime
ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value
  • DocumentEntry.serviceStartTime
  • DocumentEntry.serviceStopTime
..... id
n/a
..... extension
n/a
..... start
./low
DR.1
..... end
./high
DR.2
.... facilityType
usually from a mapping to a local ValueSet
.participation[typeCode="LOC"].role[classCode="DSDLOC"].code
usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
DocumentEntry.healthcareFacilityTypeCode
.... practiceSetting
usually from a mapping to a local ValueSet
.participation[typeCode="LOC"].role[classCode="DSDLOC"].code
usually from a mapping to a local ValueSet
DocumentEntry.practiceSettingCode
.... sourcePatientInfo
Composition.subject
.participation[typeCode="SBJ"].role[typeCode="PAT"]
ClinicalDocument/recordTarget/
  • DocumentEntry.sourcePatientInfo
  • DocumentEntry.sourcePatientId
.... related
Composition.event.detail
./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]
ClinicalDocument/relatedDocument
DocumentEntry.referenceIdList

doco Documentation for this format