{ "resourceType": "StructureDefinition", "id": "bbs-DocumentReference", "text": { "status": "empty", "div": "
No narrative is provided for definitional resources. A human-readable rendering can be found in the implementation guide(s) where this resource is used.
" }, "url": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference", "name": "BbsDocumentReference", "title": "bbs DocumentReference", "status": "active", "publisher": "MedMij", "contact": [ { "name": "MedMij", "telecom": [ { "system": "email", "value": "info@medmij.nl", "use": "work" } ] } ], "description": "Imaging study including images and reports.", "purpose": "This DocumentReference resource represents the Study 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).", "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.", "fhirVersion": "4.0.1", "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "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-medmij-dataset-100-beta1-20250807", "name": "Dataset Beeldbeschikbaarheid MedMij 1.0.0-beta.1 20250807" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "name": "Dataset Beeldbeschikbaarheid MedMij 1.0.0-rc.1 20250919" }, { "identity": "ihexds-dataset-2024-20220712", "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)" } ], "kind": "resource", "abstract": false, "type": "DocumentReference", "baseDefinition": "https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.UnContained.Comprehensive.DocumentReference", "derivation": "constraint", "snapshot": { "element": [ { "id": "DocumentReference", "path": "DocumentReference", "short": "Study", "definition": "Imaging study including images and reports.", "comment": "Usually, this is used for documents other than those defined by FHIR.", "alias": [ "Onderzoek" ], "min": 0, "max": "*", "base": { "path": "DocumentReference", "min": 0, "max": "*" }, "constraint": [ { "key": "dom-2", "severity": "error", "human": "If the resource is contained in another resource, it SHALL NOT contain nested Resources", "expression": "contained.contained.empty()", "xpath": "not(parent::f:contained and f:contained)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-4", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated", "expression": "contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-3", "severity": "error", "human": "If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource", "expression": "contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()", "xpath": "not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice", "valueBoolean": true }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bestpractice-explanation", "valueMarkdown": "When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time." } ], "key": "dom-6", "severity": "warning", "human": "A resource should have narrative for robust management", "expression": "text.`div`.exists()", "xpath": "exists(f:text/h:div)", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "dom-5", "severity": "error", "human": "If a resource is contained in another resource, it SHALL NOT have a security label", "expression": "contained.meta.security.empty()", "xpath": "not(exists(f:contained/*/f:meta/f:security))", "source": "http://hl7.org/fhir/StructureDefinition/DomainResource" }, { "key": "bbs-DocumentReference-1", "severity": "error", "human": "Either a category for an image or a report is present.", "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()", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" }, { "key": "bbs-DocumentReference-2", "severity": "error", "human": "For an image or series of images the modalities are specified.", "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()", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "workflow", "map": "Event" }, { "identity": "fhircomposition", "map": "when describing a Composition" }, { "identity": "rim", "map": "Document[classCode=\"DOC\" and moodCode=\"EVN\"]" }, { "identity": "cda", "map": "when describing a CDA" }, { "identity": "DocumentEntry-Mapping", "map": "XDS DocumentEntry: Used in the context of the IHE MHD ImplementationGuide" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-66", "comment": "Study" } ] }, { "id": "DocumentReference.id", "path": "DocumentReference.id", "short": "Logical id of this artifact", "definition": "The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.", "comment": "The only time that a resource does not have an id is when it is being submitted to the server using a create operation.", "min": 0, "max": "1", "base": { "path": "Resource.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "isSummary": true }, { "id": "DocumentReference.meta", "path": "DocumentReference.meta", "short": "Metadata about the resource", "definition": "The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.", "min": 0, "max": "1", "base": { "path": "Resource.meta", "min": 0, "max": "1" }, "type": [ { "code": "Meta" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.meta.id", "path": "DocumentReference.meta.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.meta.extension", "path": "DocumentReference.meta.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.meta.versionId", "path": "DocumentReference.meta.versionId", "short": "Version specific identifier", "definition": "The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.", "comment": "The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.", "min": 0, "max": "1", "base": { "path": "Meta.versionId", "min": 0, "max": "1" }, "type": [ { "code": "id" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.meta.lastUpdated", "path": "DocumentReference.meta.lastUpdated", "short": "When the resource version last changed", "definition": "When the resource last changed - e.g. when the version changed.", "comment": "This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http.html#read) interaction.", "min": 0, "max": "1", "base": { "path": "Meta.lastUpdated", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.meta.source", "path": "DocumentReference.meta.source", "short": "Identifies where the resource comes from", "definition": "A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.", "comment": "In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. \n\nThis element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.", "min": 0, "max": "1", "base": { "path": "Meta.source", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.meta.profile", "path": "DocumentReference.meta.profile", "short": "Profiles this resource claims to conform to", "definition": "A list of profiles (references to [StructureDefinition](structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](structuredefinition-definitions.html#StructureDefinition.url).", "comment": "It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.", "min": 0, "max": "*", "base": { "path": "Meta.profile", "min": 0, "max": "*" }, "type": [ { "code": "canonical", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/StructureDefinition" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.limitedMetadata" } ] }, { "id": "DocumentReference.meta.security", "path": "DocumentReference.meta.security", "short": "Security Labels applied to this resource", "definition": "Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.", "comment": "The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.", "min": 0, "max": "*", "base": { "path": "Meta.security", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "SecurityLabels" } ], "strength": "extensible", "description": "Security Labels from the Healthcare Privacy and Security Classification System.", "valueSet": "http://hl7.org/fhir/ValueSet/security-labels" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" } ] }, { "id": "DocumentReference.meta.tag", "path": "DocumentReference.meta.tag", "short": "Tags applied to this resource", "definition": "Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.", "comment": "The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.", "min": 0, "max": "*", "base": { "path": "Meta.tag", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Tags" } ], "strength": "example", "description": "Codes that represent various types of tags, commonly workflow-related; e.g. \"Needs review by Dr. Jones\".", "valueSet": "http://hl7.org/fhir/ValueSet/common-tags" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" } ] }, { "id": "DocumentReference.implicitRules", "path": "DocumentReference.implicitRules", "short": "A set of rules under which this content was created", "definition": "A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.", "comment": "Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.", "min": 0, "max": "1", "base": { "path": "Resource.implicitRules", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.language", "path": "DocumentReference.language", "short": "Language of the resource content", "definition": "The base language in which the resource is written.", "comment": "Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).", "min": 0, "max": "1", "base": { "path": "Resource.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "preferred", "description": "A human language.", "valueSet": "http://hl7.org/fhir/ValueSet/languages" }, "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.text", "path": "DocumentReference.text", "short": "Text summary of the resource, for human interpretation", "definition": "A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it \"clinically safe\" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.", "comment": "Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a \"text blob\" or where text is additionally entered raw or narrated and encoded information is added later.", "alias": [ "narrative", "html", "xhtml", "display" ], "min": 0, "max": "1", "base": { "path": "DomainResource.text", "min": 0, "max": "1" }, "type": [ { "code": "Narrative" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "rim", "map": "Act.text?" } ] }, { "id": "DocumentReference.contained", "path": "DocumentReference.contained", "short": "Contained, inline Resources", "definition": "These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.", "comment": "This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.", "alias": [ "inline resources", "anonymous resources", "contained resources" ], "min": 0, "max": "*", "base": { "path": "DomainResource.contained", "min": 0, "max": "*" }, "type": [ { "code": "Resource" } ], "mapping": [ { "identity": "rim", "map": "Entity. Role, or Act" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.extension", "path": "DocumentReference.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "DomainResource.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.modifierExtension", "path": "DocumentReference.modifierExtension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Extensions that cannot be ignored", "definition": "May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content" ], "min": 0, "max": "0", "base": { "path": "DomainResource.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them", "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.masterIdentifier", "path": "DocumentReference.masterIdentifier", "short": "ReportInformationIdentificationNumber / ImageInformationIdentificationNumber / UniqueID", "definition": "* Globally unique ID for the report of the imaging study. 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.", "comment": "CDA Document Id extension and root.", "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.).", "alias": [ "VerslaginformatieIdentificatienummer", "BeeldinformatieIdentificatienummer" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.masterIdentifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier", "profile": [ "https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.UniqueIdIdentifier" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "fhircomposition", "map": "Composition.identifier" }, { "identity": "v2", "map": "TXA-12" }, { "identity": "rim", "map": ".id" }, { "identity": "xds", "map": "DocumentEntry.uniqueId" }, { "identity": "cda", "map": "ClinicalDocument/id" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.uniqueId" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-100", "comment": "ReportInformationIdentificationNumber" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-784", "comment": "ImageInformationIdentificationNumber" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-29", "comment": "uniqueID" } ] }, { "id": "DocumentReference.identifier", "path": "DocumentReference.identifier", "slicing": { "discriminator": [ { "type": "value", "path": "use" } ], "rules": "open" }, "short": "Other identifiers for the document", "definition": "Other identifiers associated with the document, including version independent identifiers.", "min": 0, "max": "*", "base": { "path": "DocumentReference.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "TXA-16?" }, { "identity": "rim", "map": ".id / .setId" }, { "identity": "xds", "map": "DocumentEntry.entryUUID" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.entryUUID" } ] }, { "id": "DocumentReference.identifier:entryUUID", "path": "DocumentReference.identifier", "sliceName": "entryUUID", "short": "An identifier intended for computation", "definition": "An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.", "min": 0, "max": "*", "base": { "path": "DocumentReference.identifier", "min": 0, "max": "*" }, "type": [ { "code": "Identifier", "profile": [ "https://profiles.ihe.net/ITI/MHD/StructureDefinition/IHE.MHD.EntryUUID.Identifier" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "workflow", "map": "Event.identifier" }, { "identity": "w5", "map": "FiveWs.identifier" }, { "identity": "v2", "map": "TXA-16?" }, { "identity": "rim", "map": ".id / .setId" }, { "identity": "xds", "map": "DocumentEntry.entryUUID" } ] }, { "id": "DocumentReference.status", "path": "DocumentReference.status", "short": "AvailabilityStatus", "definition": "The lifecycle status of the document.", "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.", "min": 1, "max": "1", "base": { "path": "DocumentReference.status", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "patternCode": "current", "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "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, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentReferenceStatus" } ], "strength": "required", "description": "The status of the document reference.", "valueSet": "https://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.status" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "v2", "map": "TXA-19" }, { "identity": "rim", "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": "xds", "map": "DocumentEntry.availabilityStatus" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.availabilityStatus" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-3", "comment": "availabilityStatus" } ] }, { "id": "DocumentReference.docStatus", "path": "DocumentReference.docStatus", "short": "preliminary | final | amended | entered-in-error", "definition": "The status of the underlying document.", "comment": "The document that is pointed to might be in various lifecycle states.", "min": 0, "max": "0", "base": { "path": "DocumentReference.docStatus", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "ReferredDocumentStatus" } ], "strength": "required", "description": "Status of the underlying document.", "valueSet": "http://hl7.org/fhir/ValueSet/composition-status|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "w5", "map": "FiveWs.status" }, { "identity": "fhircomposition", "map": "Composition.status" }, { "identity": "v2", "map": "TXA-17" }, { "identity": "rim", "map": ".statusCode" } ] }, { "id": "DocumentReference.type", "path": "DocumentReference.type", "short": "ProcedureType / TypeCode", "definition": "* Description of the procedure and/or the performed imaging study (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).", "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.", "alias": [ "VerrichtingType" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80Type" } ], "strength": "extensible", "description": "Precise type of clinical document.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.133.11.1--20230808113539" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "workflow", "map": "Event.code" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "fhircomposition", "map": "Composition.type" }, { "identity": "v2", "map": "TXA-2" }, { "identity": "rim", "map": "./code" }, { "identity": "xds", "map": "DocumentEntry.type" }, { "identity": "cda", "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": "DocumentEntry-Mapping", "map": "DocumentEntry.typeCode" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-176", "comment": "ProcedureType" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-28", "comment": "typeCode" } ] }, { "id": "DocumentReference.category", "path": "DocumentReference.category", "short": "ClassCode", "definition": "The code specifying the particular kind of document.", "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.", "alias": [ "claxs" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.category", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80Class" } ], "strength": "example", "description": "High-level kind of a clinical document at a macro level.", "valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "w5", "map": "FiveWs.class" }, { "identity": "fhircomposition", "map": "Composition.class" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"COMP].target[classCode=\"LIST\", moodCode=\"EVN\"].code" }, { "identity": "xds", "map": "DocumentEntry.class" }, { "identity": "cda", "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": "DocumentEntry-Mapping", "map": "DocumentEntry.classCode" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-9", "comment": "classCode" } ] }, { "id": "DocumentReference.category.id", "path": "DocumentReference.category.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.category.extension", "path": "DocumentReference.category.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.category.coding", "path": "DocumentReference.category.coding", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 1, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "DocumentReference.category.coding:images", "path": "DocumentReference.category.coding", "sliceName": "images", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "patternCoding": { "system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1", "code": "IMAGES" }, "condition": [ "ele-1", "bbs-DocumentReference-1", "bbs-DocumentReference-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "DocumentReference.category.coding:reports", "path": "DocumentReference.category.coding", "sliceName": "reports", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "patternCoding": { "system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1", "code": "REPORTS" }, "condition": [ "ele-1", "bbs-DocumentReference-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "DocumentReference.category.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.category.text", "short": "Plain text representation of the concept", "definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "DocumentReference.subject", "path": "DocumentReference.subject", "short": "Patient / PatientId", "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).", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "alias": [ "Patient" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.subject", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.subject" }, { "identity": "w5", "map": "FiveWs.subject[x]" }, { "identity": "fhircomposition", "map": "Composition.subject" }, { "identity": "v2", "map": "PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]" }, { "identity": "xds", "map": "DocumentEntry.patientId" }, { "identity": "cda", "map": "ClinicalDocument/recordTarget/" }, { "identity": "w5", "map": "FiveWs.subject" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.patientId" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-132", "comment": "Patient" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-19", "comment": "patientId" } ] }, { "id": "DocumentReference.date", "path": "DocumentReference.date", "short": "DateTime / CreationTime", "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.", "comment": "Referencing/indexing time is used for tracking, organizing versions and searching.", "alias": [ "indexed", "DatumTijd" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.date", "min": 0, "max": "1" }, "type": [ { "code": "instant" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "workflow", "map": "Event.occurrence[x]" }, { "identity": "w5", "map": "FiveWs.recorded" }, { "identity": "fhircomposition", "map": "Composition.date" }, { "identity": "rim", "map": ".availabilityTime[type=\"TS\"]" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-101", "comment": "DateTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-69", "comment": "DateTime" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-11", "comment": "creationTime" } ] }, { "id": "DocumentReference.author", "path": "DocumentReference.author", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Author", "definition": "Identifies who is responsible for adding the information to the document.", "comment": "Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).", "min": 1, "max": "*", "base": { "path": "DocumentReference.author", "min": 0, "max": "*" }, "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" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.author" }, { "identity": "v2", "map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.author" }, { "identity": "cda", "map": "ClinicalDocument/author" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.author" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-2", "comment": "author" } ] }, { "id": "DocumentReference.author:location", "path": "DocumentReference.author", "sliceName": "location", "short": "Location", "definition": "The healthcare center where the procedure was, is or will be carried out.", "comment": "Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).", "alias": [ "Locatie" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.author", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.author" }, { "identity": "v2", "map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.author" }, { "identity": "cda", "map": "ClinicalDocument/author" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.author" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-185", "comment": "Location" } ] }, { "id": "DocumentReference.author:performer", "path": "DocumentReference.author", "sliceName": "performer", "short": "Performer", "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).", "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.", "alias": [ "Uitvoerder" ], "min": 0, "max": "*", "base": { "path": "DocumentReference.author", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.author" }, { "identity": "v2", "map": "TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)" }, { "identity": "rim", "map": ".participation[typeCode=\"AUT\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.author" }, { "identity": "cda", "map": "ClinicalDocument/author" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.author" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-187", "comment": "Performer" } ] }, { "id": "DocumentReference.authenticator", "path": "DocumentReference.authenticator", "short": "LegalAuthenticator", "definition": "Represents a participant who has legally authenticated or attested the document within the author institution.", "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.", "min": 0, "max": "1", "base": { "path": "DocumentReference.authenticator", "min": 0, "max": "1" }, "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" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "w5", "map": "FiveWs.witness" }, { "identity": "fhircomposition", "map": "Composition.attester" }, { "identity": "v2", "map": "TXA-10" }, { "identity": "rim", "map": ".participation[typeCode=\"AUTHEN\"].role[classCode=\"ASSIGNED\"]" }, { "identity": "xds", "map": "DocumentEntry.legalAuthenticator" }, { "identity": "cda", "map": "ClinicalDocument/legalAuthenticator" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.legalAuthenticator" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-17", "comment": "legalAuthenticator" } ] }, { "id": "DocumentReference.custodian", "path": "DocumentReference.custodian", "short": "Organization which maintains the document", "definition": "Identifies the organization or group who is responsible for ongoing maintenance of and access to 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.", "min": 0, "max": "1", "base": { "path": "DocumentReference.custodian", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.performer.actor" }, { "identity": "fhircomposition", "map": "Composition.custodian" }, { "identity": "rim", "map": ".participation[typeCode=\"RCV\"].role[classCode=\"CUST\"].scoper[classCode=\"ORG\" and determinerCode=\"INST\"]" }, { "identity": "DocumentEntry-Mapping", "map": "not mapped" } ] }, { "id": "DocumentReference.relatesTo", "path": "DocumentReference.relatesTo", "short": "Relationships to other documents", "definition": "Relationships that this document has with other document references that already exist.", "comment": "This element is labeled as a modifier because documents that append to other documents are incomplete on their own.", "min": 0, "max": "*", "base": { "path": "DocumentReference.relatesTo", "min": 0, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "fhircomposition", "map": "Composition.relatesTo" }, { "identity": "rim", "map": ".outboundRelationship" }, { "identity": "xds", "map": "DocumentEntry Associations" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry Associations" } ] }, { "id": "DocumentReference.relatesTo.id", "path": "DocumentReference.relatesTo.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.relatesTo.extension", "path": "DocumentReference.relatesTo.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.relatesTo.modifierExtension", "path": "DocumentReference.relatesTo.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.relatesTo.code", "path": "DocumentReference.relatesTo.code", "short": "replaces | transforms | signs | appends", "definition": "The type of relationship that this document has with anther document.", "comment": "If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.", "min": 1, "max": "1", "base": { "path": "DocumentReference.relatesTo.code", "min": 1, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentRelationshipType" } ], "strength": "required", "description": "The type of relationship between documents.", "valueSet": "http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "fhircomposition", "map": "Composition.relatesTo.code" }, { "identity": "rim", "map": ".outboundRelationship.typeCode" }, { "identity": "xds", "map": "DocumentEntry Associations type" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry Associations.type" } ] }, { "id": "DocumentReference.relatesTo.target", "path": "DocumentReference.relatesTo.target", "short": "Target of the relationship", "definition": "The target document of this relationship.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 1, "max": "1", "base": { "path": "DocumentReference.relatesTo.target", "min": 1, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/DocumentReference" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "fhircomposition", "map": "Composition.relatesTo.target" }, { "identity": "rim", "map": ".target[classCode=\"DOC\", moodCode=\"EVN\"].id" }, { "identity": "xds", "map": "DocumentEntry Associations reference" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry Associations.reference" } ] }, { "id": "DocumentReference.description", "path": "DocumentReference.description", "short": "Comments", "definition": "Comments associated with the document.", "comment": "What the document is about, a terse summary of the document.", "requirements": "Helps humans to assess whether the document is of interest.", "min": 0, "max": "1", "base": { "path": "DocumentReference.description", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "TXA-25" }, { "identity": "rim", "map": ".outboundRelationship[typeCode=\"SUBJ\"].target.text" }, { "identity": "xds", "map": "DocumentEntry.comments" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.comments" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-4", "comment": "comments" } ] }, { "id": "DocumentReference.securityLabel", "path": "DocumentReference.securityLabel", "short": "ConfidentialityCode", "definition": "The code specifying the level of confidentiality of the document.", "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.", "requirements": "Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.", "min": 1, "max": "*", "base": { "path": "DocumentReference.securityLabel", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "SecurityLabels" } ], "strength": "extensible", "description": "Security Labels from the Healthcare Privacy and Security Classification System.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.6--20131212104106" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "Composition.confidentiality, Composition.meta.security" }, { "identity": "v2", "map": "TXA-18" }, { "identity": "rim", "map": ".confidentialityCode" }, { "identity": "xds", "map": "DocumentEntry.confidentialityCode" }, { "identity": "cda", "map": "ClinicalDocument/confidentialityCode/@code" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.confidentialityCode" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-10", "comment": "confidentialityCode" } ] }, { "id": "DocumentReference.content", "path": "DocumentReference.content", "short": "Document referenced", "definition": "The document and format referenced.", "min": 1, "max": "1", "base": { "path": "DocumentReference.content", "min": 1, "max": "*" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "fhircomposition", "map": "Bundle(Composition+*)" }, { "identity": "rim", "map": "document.text" } ] }, { "id": "DocumentReference.content.id", "path": "DocumentReference.content.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.extension", "path": "DocumentReference.content.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.content.modifierExtension", "path": "DocumentReference.content.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.content.attachment", "path": "DocumentReference.content.attachment", "short": "Where to access the document", "definition": "The document or URL of the document along with critical metadata to prove content has integrity.", "comment": "When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as \"Signed Procedure Consent\".", "min": 1, "max": "1", "base": { "path": "DocumentReference.content.attachment", "min": 1, "max": "1" }, "type": [ { "code": "Attachment" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "att-1", "severity": "error", "human": "If the Attachment has data, it SHALL have a contentType", "expression": "data.empty() or contentType.exists()", "xpath": "not(exists(f:data)) or exists(f:contentType)", "source": "http://hl7.org/fhir/StructureDefinition/Attachment" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ED/RP" }, { "identity": "rim", "map": "ED" }, { "identity": "fhircomposition", "map": "Composition.language, \nComposition.title, \nComposition.date" }, { "identity": "v2", "map": "TXA-3 for mime type" }, { "identity": "rim", "map": "document.text" }, { "identity": "xds", "map": "DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime" }, { "identity": "cda", "map": "ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date" } ] }, { "id": "DocumentReference.content.attachment.id", "path": "DocumentReference.content.attachment.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.content.attachment.extension", "path": "DocumentReference.content.attachment.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.content.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "short": "MimeType", "definition": "MIME type of the document.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "requirements": "Processors of the data need to be able to know how to interpret the data.", "min": 1, "max": "1", "base": { "path": "Attachment.contentType", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "example": [ { "label": "General", "valueCode": "text/plain; charset=UTF-8, image/png" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "MimeType" }, { "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" } ], "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding" } ], "strength": "required", "description": "The mime type of an attachment. Any valid mime type is allowed.", "valueSet": "http://hl7.org/fhir/ValueSet/mimetypes|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used" }, { "identity": "rim", "map": "./mediaType, ./charset" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.mimeType" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-18", "comment": "mimeType" } ] }, { "id": "DocumentReference.content.attachment.language", "path": "DocumentReference.content.attachment.language", "short": "LanguageCode", "definition": "Specifies the human language of character data in the document. Using codes from IETF RFC 3066.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "requirements": "Users need to be able to choose between the languages in a set of attachments.", "min": 1, "max": "1", "base": { "path": "Attachment.language", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "example": [ { "label": "General", "valueCode": "en-AU" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-maxValueSet", "valueCanonical": "http://hl7.org/fhir/ValueSet/all-languages" }, { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "Language" } ], "strength": "extensible", "description": "A human language.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.12--20131212104106" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "./language" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.languageCode" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-16", "comment": "languageCode" } ] }, { "id": "DocumentReference.content.attachment.data", "path": "DocumentReference.content.attachment.data", "short": "Data inline, base64ed", "definition": "The actual data of the attachment - a sequence of bytes, base64 encoded.", "comment": "The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.", "requirements": "The data needs to able to be transmitted inline.", "min": 0, "max": "0", "base": { "path": "Attachment.data", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "ED.5" }, { "identity": "rim", "map": "./data" } ] }, { "id": "DocumentReference.content.attachment.url", "path": "DocumentReference.content.attachment.url", "short": "URI", "definition": "The URI for the document.", "comment": "If both data and url are provided, the url SHALL point to the same content as the data contains. Urls may be relative references or may reference transient locations such as a wrapping envelope using cid: though this has ramifications for using signatures. Relative URLs are interpreted relative to the service url, like a resource reference, rather than relative to the resource itself. If a URL is provided, it SHALL resolve to actual data.", "requirements": "The data needs to be transmitted by reference.", "min": 1, "max": "1", "base": { "path": "Attachment.url", "min": 0, "max": "1" }, "type": [ { "code": "url" } ], "example": [ { "label": "General", "valueUrl": "http://www.acme.com/logo-small.png" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "RP.1+RP.2 - if they refer to a URL (see v2.6)" }, { "identity": "rim", "map": "./reference/literal" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.repositoryUniqueId or DocuemntEntry.URI" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-30", "comment": "URI" } ] }, { "id": "DocumentReference.content.attachment.size", "path": "DocumentReference.content.attachment.size", "short": "Size", "definition": "Size in bytes of the document.", "comment": "The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.", "requirements": "Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.", "min": 0, "max": "1", "base": { "path": "Attachment.size", "min": 0, "max": "1" }, "type": [ { "code": "unsignedInt" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A (needs data type R3 proposal)" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.size" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-24", "comment": "size" } ] }, { "id": "DocumentReference.content.attachment.hash", "path": "DocumentReference.content.attachment.hash", "short": "Hash", "definition": "Hash of the document itself.", "comment": "The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.", "requirements": "Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).", "min": 0, "max": "1", "base": { "path": "Attachment.hash", "min": 0, "max": "1" }, "type": [ { "code": "base64Binary" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": ".integrityCheck[parent::ED/integrityCheckAlgorithm=\"SHA-1\"]" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.hash" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-14", "comment": "hash" } ] }, { "id": "DocumentReference.content.attachment.title", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.content.attachment.title", "short": "ReportTitle / ImageTitle / Title", "definition": "* The title of the report.\n* The title of the image.\n* The title of the document.", "comment": "Note that FHIR strings SHALL NOT exceed 1MB in size", "requirements": "Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.", "alias": [ "VerslagTitel", "BeeldTitel" ], "min": 0, "max": "1", "base": { "path": "Attachment.title", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "Official Corporate Logo" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "./title/data" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.title" }, { "identity": "bbs-medmij-dataset-100-beta1-20250807", "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-rc1-20250919", "map": "bbs-medmij-dataelement-2", "comment": "ReportTitle" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-1", "comment": "ImageTitle" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-27", "comment": "title" } ] }, { "id": "DocumentReference.content.attachment.creation", "path": "DocumentReference.content.attachment.creation", "short": "DateTime / CreationTime", "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.", "requirements": "This is often tracked as an integrity issue for use of the attachment.", "alias": [ "DatumTijd" ], "min": 1, "max": "1", "base": { "path": "Attachment.creation", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A (needs data type R3 proposal)" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.creationTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-101", "comment": "DateTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-69", "comment": "DateTime" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-11", "comment": "creationTime" } ] }, { "id": "DocumentReference.content.format", "path": "DocumentReference.content.format", "short": "FormatCode", "definition": "Code globally uniquely specifying the format of the document.", "comment": "Note that while IHE mostly issues URNs for format types, not all documents can be identified by a URI.", "min": 1, "max": "1", "base": { "path": "DocumentReference.content.format", "min": 0, "max": "1" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentFormat" } ], "strength": "extensible", "description": "Document Format Codes.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.7--20131212104106" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "fhircomposition", "map": "Composition.meta.profile" }, { "identity": "rim", "map": "document.text" }, { "identity": "xds", "map": "DocumentEntry.formatCode" }, { "identity": "cda", "map": "derived from the IHE Profile or Implementation Guide templateID" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.formatCode" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-13", "comment": "formatCode" } ] }, { "id": "DocumentReference.context", "path": "DocumentReference.context", "short": "Clinical context of document", "definition": "The clinical context in which the document was prepared.", "comment": "These values are primarily added to help with searching for interesting/relevant documents.", "min": 1, "max": "1", "base": { "path": "DocumentReference.context", "min": 0, "max": "1" }, "type": [ { "code": "BackboneElement" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "outboundRelationship[typeCode=\"SUBJ\"].target[classCode<'ACT']" } ] }, { "id": "DocumentReference.context.id", "path": "DocumentReference.context.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.extension", "path": "DocumentReference.context.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.modifierExtension", "path": "DocumentReference.context.modifierExtension", "short": "Extensions that cannot be ignored even if unrecognized", "definition": "May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.\n\nModifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "requirements": "Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).", "alias": [ "extensions", "user content", "modifiers" ], "min": 0, "max": "*", "base": { "path": "BackboneElement.modifierExtension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "isModifier": true, "isModifierReason": "Modifier extensions are expected to modify the meaning or interpretation of the element that contains them", "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.encounter", "path": "DocumentReference.context.encounter", "short": "ReferenceIdList", "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.", "comment": "Only Encounters on the ReferenceIdList are conveyed here, while other identifiers on that list are conveyed via `.context.related`.", "min": 0, "max": "*", "base": { "path": "DocumentReference.context.encounter", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Encounter" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "workflow", "map": "Event.context" }, { "identity": "w5", "map": "FiveWs.context" }, { "identity": "fhircomposition", "map": "Composition.encounter" }, { "identity": "rim", "map": "unique(highest(./outboundRelationship[typeCode=\"SUBJ\" and isNormalActRelationship()], priorityNumber)/target[moodCode=\"EVN\" and classCode=(\"ENC\", \"PCPR\") and isNormalAct])" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.referenceIdList with CXi encoding for urn:ihe:iti:xds:2015:encounterId" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-117", "comment": "referenceIdList" } ] }, { "id": "DocumentReference.context.event", "path": "DocumentReference.context.event", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "short": "EventCodeList", "definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, 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.", "min": 0, "max": "*", "base": { "path": "DocumentReference.context.event", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentEventType" } ], "strength": "example", "description": "This list of codes represents the main clinical acts being documented.", "valueSet": "http://terminology.hl7.org/ValueSet/v3-ActCode" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "Composition.event.code" }, { "identity": "rim", "map": ".code" }, { "identity": "xds", "map": "DocumentEntry.eventCodeList" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.eventCodeList" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-12", "comment": "eventCodeList" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation", "path": "DocumentReference.context.event", "sliceName": "procedureAnatomicalLocation", "short": "ProcedureAnatomicalLocation / Location", "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.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "Locatie", "nl-core-AnatomicalLocation", "VerrichtingAnatomischeLocatie" ], "min": 0, "max": "1", "base": { "path": "DocumentReference.context.event", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept", "profile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-AnatomicalLocation" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentEventType" } ], "strength": "required", "description": "This list of codes represents the main clinical acts being documented.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.19--20240205123345" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "Composition.event.code" }, { "identity": "rim", "map": ".code" }, { "identity": "xds", "map": "DocumentEntry.eventCodeList" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.eventCodeList" }, { "identity": "zib-anatomicallocation-v1.0-2020EN", "map": "NL-CM:20.7.4", "comment": "Location" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-178", "comment": "ProcedureAnatomicalLocation" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-179", "comment": "Location" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.id", "path": "DocumentReference.context.event.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension", "path": "DocumentReference.context.event.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality", "path": "DocumentReference.context.event.extension", "sliceName": "laterality", "short": "Optional Extensions Element", "definition": "Optional Extension Element - found in all resources.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "1", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension", "profile": [ "http://nictiz.nl/fhir/StructureDefinition/ext-AnatomicalLocation.Laterality" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality.id", "path": "DocumentReference.context.event.extension.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality.extension", "path": "DocumentReference.context.event.extension.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality.url", "path": "DocumentReference.context.event.extension.url", "representation": [ "xmlAttr" ], "short": "identifies the meaning of the extension", "definition": "Source of the definition for the extension code - a logical name or a URL.", "comment": "The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.", "min": 1, "max": "1", "base": { "path": "Extension.url", "min": 1, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "uri" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "fixedUri": "http://nictiz.nl/fhir/StructureDefinition/ext-AnatomicalLocation.Laterality", "mapping": [ { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.extension:laterality.value[x]", "path": "DocumentReference.context.event.extension.value[x]", "short": "Laterality", "definition": "Laterality adds information about body site to the anatomic location, e.g. left.", "alias": [ "Lateraliteit" ], "min": 0, "max": "1", "base": { "path": "Extension.value[x]", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "strength": "required", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.20.7.2--20200901000000" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "zib-anatomicallocation-v1.0-2020EN", "map": "NL-CM:20.7.3", "comment": "Laterality" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-180", "comment": "Laterality" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.coding", "path": "DocumentReference.context.event.coding", "short": "Code defined by a terminology system", "definition": "A reference to a code defined by a terminology system.", "comment": "Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.", "requirements": "Allows for alternative encodings within a code system, and translations to other code systems.", "min": 0, "max": "*", "base": { "path": "CodeableConcept.coding", "min": 0, "max": "*" }, "type": [ { "code": "Coding" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE subset one of the sets of component 1-3 or 4-6" }, { "identity": "rim", "map": "CV" }, { "identity": "orim", "map": "fhir:Coding rdfs:subClassOf dt:CDCoding" }, { "identity": "v2", "map": "C*E.1-8, C*E.10-22" }, { "identity": "rim", "map": "union(., ./translation)" }, { "identity": "orim", "map": "fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation.text", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.context.event.text", "short": "Plain text representation of the concept", "definition": "A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.", "comment": "Very often the text is the same as a displayName of one of the codings.", "requirements": "The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.", "min": 0, "max": "1", "base": { "path": "CodeableConcept.text", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "C*E.9. But note many systems use C*E.2 for this" }, { "identity": "rim", "map": "./originalText[mediaType/code=\"text/plain\"]/data" }, { "identity": "orim", "map": "fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText" } ] }, { "id": "DocumentReference.context.event:modality", "path": "DocumentReference.context.event", "sliceName": "modality", "short": "Modality", "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.", "comment": "For an image or series of images the modalities SHALL be specified.", "alias": [ "Modaliteit" ], "min": 0, "max": "*", "base": { "path": "DocumentReference.context.event", "min": 0, "max": "*" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1", "bbs-DocumentReference-2" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentEventType" }, { "extension": [ { "url": "key", "valueId": "bbs-DocumentReference-binding-modality-1" }, { "url": "purpose", "valueCode": "minimum" }, { "url": "valueSet", "valueCanonical": "http://medmij.nl/fhir/ValueSet/Modality" } ], "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding" } ], "strength": "required", "description": "This list of codes represents the main clinical acts being documented.", "valueSet": "http://medmij.nl/fhir/ValueSet/ModalityCombined" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "Composition.event.code" }, { "identity": "rim", "map": ".code" }, { "identity": "xds", "map": "DocumentEntry.eventCodeList" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.eventCodeList" }, { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-5", "comment": "Modality" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-5", "comment": "Modality" } ] }, { "id": "DocumentReference.context.period", "path": "DocumentReference.context.period", "short": "Time of service that is being documented", "definition": "The time period over which the service that is described by the document was provided.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 1, "max": "1", "base": { "path": "DocumentReference.context.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start <= end)", "xpath": "not(exists(f:start/@value)) or not(exists(f:end/@value)) or (xs:dateTime(f:start/@value) <= xs:dateTime(f:end/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "mustSupport": true, "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "fhircomposition", "map": "Composition.event.period" }, { "identity": "rim", "map": ".effectiveTime" }, { "identity": "xds", "map": "DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime" }, { "identity": "cda", "map": "ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/low/\n@value --> ClinicalDocument/documentationOf/\nserviceEvent/effectiveTime/high/\n@value" } ] }, { "id": "DocumentReference.context.period.id", "path": "DocumentReference.context.period.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.period.extension", "path": "DocumentReference.context.period.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.period.start", "path": "DocumentReference.context.period.start", "short": "ProcedureStartDate / ServiceStartTime", "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.", "comment": "If the low element is missing, the meaning is that the low boundary is not known.", "alias": [ "VerrichtingStartDatum" ], "min": 1, "max": "1", "base": { "path": "Period.start", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.1" }, { "identity": "rim", "map": "./low" }, { "identity": "DocumentEntry-Mapping", "map": "DocumetEntry.serviceStartTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-174", "comment": "ProcedureStartDate" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-22", "comment": "serviceStartTime" } ] }, { "id": "DocumentReference.context.period.end", "path": "DocumentReference.context.period.end", "short": "ProcedureEndDate / ServiceStopTime", "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.", "comment": "The high value includes any matching date/time. i.e. 2012-02-03T10:00:00 is in a period that has an end value of 2012-02-03.", "alias": [ "VerrichtingEindDatum" ], "min": 0, "max": "1", "base": { "path": "Period.end", "min": 0, "max": "1" }, "type": [ { "code": "dateTime" } ], "meaningWhenMissing": "If the end of the period is missing, it means that the period is ongoing", "condition": [ "ele-1", "per-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR.2" }, { "identity": "rim", "map": "./high" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.serviceStopTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-175", "comment": "ProcedureEndDate" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-23", "comment": "serviceStopTime" } ] }, { "id": "DocumentReference.context.facilityType", "path": "DocumentReference.context.facilityType", "short": "OrganizationType / HealthcareFacilityTypeCode", "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.", "comment": "Not all terminology uses fit this general pattern. In some cases, models should not use CodeableConcept and use Coding directly and provide their own structure for managing text, codings, translations and the relationship between elements and pre- and post-coordination.", "alias": [ "OrganisatieType" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.context.facilityType", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80FacilityType" } ], "strength": "extensible", "description": "XDS Facility Type.", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.40.2.17.2.3--20200901000000" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "usually from a mapping to a local ValueSet" }, { "identity": "rim", "map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code" }, { "identity": "xds", "map": "DocumentEntry.healthcareFacilityTypeCode" }, { "identity": "cda", "map": "usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.healthcareFacilityTypeCode" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-546", "comment": "OrganizationType" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-31", "comment": "healthcareFacilityTypeCode" } ] }, { "id": "DocumentReference.context.practiceSetting", "path": "DocumentReference.context.practiceSetting", "short": "DepartmentSpecialty / PracticeSettingCode", "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).", "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.", "requirements": "This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.", "alias": [ "AfdelingSpecialisme" ], "min": 1, "max": "1", "base": { "path": "DocumentReference.context.practiceSetting", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "mustSupport": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "DocumentC80PracticeSetting" } ], "strength": "required", "description": "Additional details about where the content was created (e.g. clinical specialty).", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.22--20240205133006" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "fhircomposition", "map": "usually from a mapping to a local ValueSet" }, { "identity": "rim", "map": ".participation[typeCode=\"LOC\"].role[classCode=\"DSDLOC\"].code" }, { "identity": "xds", "map": "DocumentEntry.practiceSettingCode" }, { "identity": "cda", "map": "usually from a mapping to a local ValueSet" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.practiceSettingCode" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-524", "comment": "DepartmentSpecialty" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-20", "comment": "practiceSettingCode" } ] }, { "id": "DocumentReference.context.sourcePatientInfo", "path": "DocumentReference.context.sourcePatientInfo", "short": "SourcePatientId / SourcePatientInfo", "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.", "comment": "References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.", "min": 1, "max": "1", "base": { "path": "DocumentReference.context.sourcePatientInfo", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mustSupport": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "fhircomposition", "map": "Composition.subject" }, { "identity": "rim", "map": ".participation[typeCode=\"SBJ\"].role[typeCode=\"PAT\"]" }, { "identity": "xds", "map": "DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId" }, { "identity": "cda", "map": "ClinicalDocument/recordTarget/" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-25", "comment": "sourcePatientId" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-26", "comment": "sourcePatientInfo" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.id", "path": "DocumentReference.context.sourcePatientInfo.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.extension", "path": "DocumentReference.context.sourcePatientInfo.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.reference", "path": "DocumentReference.context.sourcePatientInfo.reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.", "comment": "Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure \"/[type]/[id]\" then it should be assumed that the reference is to a FHIR RESTful server.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1", "ref-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.sourcePatientInfo" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.type", "path": "DocumentReference.context.sourcePatientInfo.type", "short": "Type the reference refers to (e.g. \"Patient\")", "definition": "The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "comment": "This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.", "min": 0, "max": "1", "base": { "path": "Reference.type", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FHIRResourceTypeExt" } ], "strength": "extensible", "description": "Aa resource (or, for logical models, the URI of the logical model).", "valueSet": "http://hl7.org/fhir/ValueSet/resource-types" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.identifier", "path": "DocumentReference.context.sourcePatientInfo.identifier", "short": "Logical reference, when literal reference is not known", "definition": "An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.", "comment": "When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).", "min": 0, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "rim", "map": ".identifier" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.sourcePatientId" } ] }, { "id": "DocumentReference.context.sourcePatientInfo.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.context.sourcePatientInfo.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "comment": "This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related", "path": "DocumentReference.context.related", "slicing": { "discriminator": [ { "type": "value", "path": "identifier.type" } ], "rules": "open" }, "short": "ReferenceIdList", "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.", "comment": "Encounters on the ReferenceIdList are conveyed via `.context.encounter`.", "min": 0, "max": "*", "base": { "path": "DocumentReference.context.related", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "fhircomposition", "map": "Composition.event.detail" }, { "identity": "rim", "map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]" }, { "identity": "xds", "map": "DocumentEntry.referenceIdList" }, { "identity": "cda", "map": "ClinicalDocument/relatedDocument" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.referenceIdList using CXi encoding for type when possible" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-117", "comment": "referenceIdList" } ] }, { "id": "DocumentReference.context.related:accessionNumber", "path": "DocumentReference.context.related", "sliceName": "accessionNumber", "short": "Related identifiers or resources", "definition": "Related identifiers or resources associated with the DocumentReference.", "comment": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.related", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "fhircomposition", "map": "Composition.event.detail" }, { "identity": "rim", "map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]" }, { "identity": "xds", "map": "DocumentEntry.referenceIdList" }, { "identity": "cda", "map": "ClinicalDocument/relatedDocument" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.referenceIdList using CXi encoding for type when possible" } ] }, { "id": "DocumentReference.context.related:accessionNumber.id", "path": "DocumentReference.context.related.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.related:accessionNumber.extension", "path": "DocumentReference.context.related.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:accessionNumber.reference", "path": "DocumentReference.context.related.reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.", "comment": "Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure \"/[type]/[id]\" then it should be assumed that the reference is to a FHIR RESTful server.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1", "ref-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:accessionNumber.type", "path": "DocumentReference.context.related.type", "short": "Type the reference refers to (e.g. \"Patient\")", "definition": "The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "comment": "This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.", "min": 0, "max": "1", "base": { "path": "Reference.type", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FHIRResourceTypeExt" } ], "strength": "extensible", "description": "Aa resource (or, for logical models, the URI of the logical model).", "valueSet": "http://hl7.org/fhir/ValueSet/resource-types" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier", "path": "DocumentReference.context.related.identifier", "short": "AccessionNumber", "definition": "A locally unique record number in the RIS that identifies the imaging procedure request.", "comment": "When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).", "alias": [ "AccessionNumber" ], "min": 1, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "rim", "map": ".identifier" }, { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-3", "comment": "AccessionNumber" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-3", "comment": "AccessionNumber" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.id", "path": "DocumentReference.context.related.identifier.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.extension", "path": "DocumentReference.context.related.identifier.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.use", "path": "DocumentReference.context.related.identifier.use", "short": "usual | official | temp | secondary | old (If known)", "definition": "The purpose of this identifier.", "comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierUse" } ], "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.type", "path": "DocumentReference.context.related.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 1, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "patternCodeableConcept": { "coding": [ { "system": "urn:ietf:rfc:3986", "code": "urn:ihe:iti:xds:2013:accession" } ] }, "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierType" } ], "strength": "extensible", "description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.system", "path": "DocumentReference.context.related.identifier.system", "short": "The namespace for the identifier value", "definition": "Establishes the namespace for the value - that is, a URL that describes a set values that are unique.", "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` SHOULD 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).", "requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "example": [ { "label": "General", "valueUri": "http://www.acme.com/identifiers/patient" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-7", "comment": "AssigningAuthority (implicit, main mapping is on .context.related[accessionNumber].identifier.assigner)" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.value", "path": "DocumentReference.context.related.identifier.value", "short": "The value that is unique", "definition": "The portion of the identifier typically relevant to the user and which is unique within the context of the system.", "comment": "If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the [Rendered Value extension](extension-rendered-value.html). Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.", "min": 1, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "123456" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.period", "path": "DocumentReference.context.related.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start <= end)", "xpath": "not(exists(f:start/@value)) or not(exists(f:end/@value)) or (xs:dateTime(f:start/@value) <= xs:dateTime(f:end/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.assigner", "path": "DocumentReference.context.related.identifier.assigner", "short": "AssigningAuthority", "definition": "Assigning authority that issued the Accession Number.", "comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.", "alias": [ "UitgevendeInstantie" ], "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-7", "comment": "AssigningAuthority" } ] }, { "id": "DocumentReference.context.related:accessionNumber.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.context.related.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "comment": "This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID", "path": "DocumentReference.context.related", "sliceName": "studyInstanceUID", "short": "Related identifiers or resources", "definition": "Related identifiers or resources associated with the DocumentReference.", "comment": "May be identifiers or resources that caused the DocumentReference or referenced Document to be created.", "min": 0, "max": "1", "base": { "path": "DocumentReference.context.related", "min": 0, "max": "*" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Resource" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "fhircomposition", "map": "Composition.event.detail" }, { "identity": "rim", "map": "./outboundRelationship[typeCode=\"PERT\" and isNormalActRelationship()] / target[isNormalAct]" }, { "identity": "xds", "map": "DocumentEntry.referenceIdList" }, { "identity": "cda", "map": "ClinicalDocument/relatedDocument" }, { "identity": "DocumentEntry-Mapping", "map": "DocumentEntry.referenceIdList using CXi encoding for type when possible" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.id", "path": "DocumentReference.context.related.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.extension", "path": "DocumentReference.context.related.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.reference", "path": "DocumentReference.context.related.reference", "short": "Literal reference, Relative, internal or absolute URL", "definition": "A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.", "comment": "Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure \"/[type]/[id]\" then it should be assumed that the reference is to a FHIR RESTful server.", "min": 0, "max": "1", "base": { "path": "Reference.reference", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1", "ref-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.type", "path": "DocumentReference.context.related.type", "short": "Type the reference refers to (e.g. \"Patient\")", "definition": "The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.\n\nThe type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. \"Patient\" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).", "comment": "This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.", "min": 0, "max": "1", "base": { "path": "Reference.type", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "FHIRResourceTypeExt" } ], "strength": "extensible", "description": "Aa resource (or, for logical models, the URI of the logical model).", "valueSet": "http://hl7.org/fhir/ValueSet/resource-types" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier", "path": "DocumentReference.context.related.identifier", "short": "StudyInstanceUID", "definition": "The globally unique DICOM identifier of the imaging study upon which the imaging report is based, assigned by the modality or PACS.", "comment": "When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. \n\nWhen both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference\n\nApplications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.\n\nReference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).", "alias": [ "StudyInstanceUID" ], "min": 1, "max": "1", "base": { "path": "Reference.identifier", "min": 0, "max": "1" }, "type": [ { "code": "Identifier" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX / EI (occasionally, more often EI maps to a resource id or a URL)" }, { "identity": "rim", "map": "II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT]" }, { "identity": "servd", "map": "Identifier" }, { "identity": "rim", "map": ".identifier" }, { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-4", "comment": "StudyInstanceUID" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-4", "comment": "StudyInstanceUID" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.id", "path": "DocumentReference.context.related.identifier.id", "representation": [ "xmlAttr" ], "short": "Unique id for inter-element referencing", "definition": "Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.", "min": 0, "max": "1", "base": { "path": "Element.id", "min": 0, "max": "1" }, "type": [ { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/structuredefinition-fhir-type", "valueUrl": "string" } ], "code": "http://hl7.org/fhirpath/System.String" } ], "mapping": [ { "identity": "rim", "map": "n/a" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.extension", "path": "DocumentReference.context.related.identifier.extension", "slicing": { "discriminator": [ { "type": "value", "path": "url" } ], "description": "Extensions are always sliced by (at least) url", "rules": "open" }, "short": "Additional content defined by implementations", "definition": "May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.", "comment": "There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.", "alias": [ "extensions", "user content" ], "min": 0, "max": "*", "base": { "path": "Element.extension", "min": 0, "max": "*" }, "type": [ { "code": "Extension" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ext-1", "severity": "error", "human": "Must have either extensions or value[x], not both", "expression": "extension.exists() != value.exists()", "xpath": "exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])", "source": "http://hl7.org/fhir/StructureDefinition/Extension" } ], "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.use", "path": "DocumentReference.context.related.identifier.use", "short": "usual | official | temp | secondary | old (If known)", "definition": "The purpose of this identifier.", "comment": "Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.", "requirements": "Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.", "min": 0, "max": "1", "base": { "path": "Identifier.use", "min": 0, "max": "1" }, "type": [ { "code": "code" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isModifier": true, "isModifierReason": "This is labeled as \"Is Modifier\" because applications should not mistake a temporary id for a permanent one.", "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierUse" } ], "strength": "required", "description": "Identifies the purpose for this identifier, if known .", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-use|4.0.1" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "N/A" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.type", "path": "DocumentReference.context.related.identifier.type", "short": "Description of identifier", "definition": "A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.", "comment": "This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.", "requirements": "Allows users to make use of identifiers when the identifier system is not known.", "min": 1, "max": "1", "base": { "path": "Identifier.type", "min": 0, "max": "1" }, "type": [ { "code": "CodeableConcept" } ], "patternCodeableConcept": { "coding": [ { "system": "urn:ietf:rfc:3986", "code": "urn:ihe:iti:xds:2016:studyInstanceUID" } ] }, "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "IdentifierType" } ], "strength": "extensible", "description": "A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.", "valueSet": "http://hl7.org/fhir/ValueSet/identifier-type" }, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CE/CNE/CWE" }, { "identity": "rim", "map": "CD" }, { "identity": "orim", "map": "fhir:CodeableConcept rdfs:subClassOf dt:CD" }, { "identity": "v2", "map": "CX.5" }, { "identity": "rim", "map": "Role.code or implied by context" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.system", "path": "DocumentReference.context.related.identifier.system", "short": "The namespace for the identifier value", "definition": "Establishes the namespace for the value - that is, a URL that describes a set values that are unique.", "comment": "Identifier.system is always case sensitive.", "requirements": "There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.", "min": 1, "max": "1", "base": { "path": "Identifier.system", "min": 0, "max": "1" }, "type": [ { "code": "uri" } ], "patternUri": "urn:dicom:uid", "example": [ { "label": "General", "valueUri": "http://www.acme.com/identifiers/patient" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.4 / EI-2-4" }, { "identity": "rim", "map": "II.root or Role.id.root" }, { "identity": "servd", "map": "./IdentifierType" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.value", "path": "DocumentReference.context.related.identifier.value", "short": "The value that is unique", "definition": "The portion of the identifier typically relevant to the user and which is unique within the context of the system.", "comment": "As the Study Instance UID is a DICOM UID, its value SHALL be prefixed with _urn:oid:_.", "min": 1, "max": "1", "base": { "path": "Identifier.value", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "example": [ { "label": "General", "valueString": "123456" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "bbs-DocumentReference-3", "severity": "error", "human": "Each DICOM UID value is a proper OID.", "expression": "$this.startsWith('urn:oid:')", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "CX.1 / EI.1" }, { "identity": "rim", "map": "II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)" }, { "identity": "servd", "map": "./Value" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.period", "path": "DocumentReference.context.related.identifier.period", "short": "Time period when id is/was valid for use", "definition": "Time period during which identifier is/was valid for use.", "comment": "A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. \"the patient was an inpatient of the hospital for this time range\") or one value from the range applies (e.g. \"give to the patient between these two times\").\n\nPeriod is not used for a duration (a measure of elapsed time). See [Duration](datatypes.html#Duration).", "min": 0, "max": "1", "base": { "path": "Identifier.period", "min": 0, "max": "1" }, "type": [ { "code": "Period" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "per-1", "severity": "error", "human": "If present, start SHALL have a lower value than end", "expression": "start.hasValue().not() or end.hasValue().not() or (start <= end)", "xpath": "not(exists(f:start/@value)) or not(exists(f:end/@value)) or (xs:dateTime(f:start/@value) <= xs:dateTime(f:end/@value))", "source": "http://hl7.org/fhir/StructureDefinition/Period" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "v2", "map": "DR" }, { "identity": "rim", "map": "IVL[lowClosed=\"true\" and highClosed=\"true\"] or URG[lowClosed=\"true\" and highClosed=\"true\"]" }, { "identity": "v2", "map": "CX.7 + CX.8" }, { "identity": "rim", "map": "Role.effectiveTime or implied by context" }, { "identity": "servd", "map": "./StartDate and ./EndDate" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.assigner", "path": "DocumentReference.context.related.identifier.assigner", "short": "Organization that issued id (may be just text)", "definition": "Organization that issued/manages the identifier.", "comment": "The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.", "min": 0, "max": "1", "base": { "path": "Identifier.assigner", "min": 0, "max": "1" }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization" ] } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" }, { "key": "ref-1", "severity": "error", "human": "SHALL have a contained resource if a local reference is provided", "expression": "reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))", "xpath": "not(starts-with(f:reference/@value, '#')) or exists(ancestor::*[self::f:entry or self::f:parameter]/f:resource/f:*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')]|/*/f:contained/f:*[f:id/@value=substring-after(current()/f:reference/@value, '#')])", "source": "http://hl7.org/fhir/StructureDefinition/Reference" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "The target of a resource reference is a RIM entry point (Act, Role, or Entity)" }, { "identity": "v2", "map": "CX.4 / (CX.4,CX.9,CX.10)" }, { "identity": "rim", "map": "II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper" }, { "identity": "servd", "map": "./IdentifierIssuingAuthority" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.display", "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-translatable", "valueBoolean": true } ], "path": "DocumentReference.context.related.display", "short": "Text alternative for the resource", "definition": "Plain text narrative that identifies the resource in addition to the resource reference.", "comment": "This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.", "min": 0, "max": "1", "base": { "path": "Reference.display", "min": 0, "max": "1" }, "type": [ { "code": "string" } ], "condition": [ "ele-1" ], "constraint": [ { "key": "ele-1", "severity": "error", "human": "All FHIR elements must have a @value or children", "expression": "hasValue() or (children().count() > id.count())", "xpath": "@value|f:*|h:div", "source": "http://hl7.org/fhir/StructureDefinition/Element" } ], "isSummary": true, "mapping": [ { "identity": "rim", "map": "n/a" }, { "identity": "rim", "map": "N/A" } ] } ] }, "differential": { "element": [ { "id": "DocumentReference", "path": "DocumentReference", "short": "Study", "definition": "Imaging study including images and reports.", "alias": [ "Onderzoek" ], "constraint": [ { "key": "bbs-DocumentReference-1", "severity": "error", "human": "Either a category for an image or a report is present.", "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()", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" }, { "key": "bbs-DocumentReference-2", "severity": "error", "human": "For an image or series of images the modalities are specified.", "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()", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" } ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-66", "comment": "Study" } ] }, { "id": "DocumentReference.masterIdentifier", "path": "DocumentReference.masterIdentifier", "short": "ReportInformationIdentificationNumber / ImageInformationIdentificationNumber / UniqueID", "definition": "* Globally unique ID for the report of the imaging study. 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.", "alias": [ "VerslaginformatieIdentificatienummer", "BeeldinformatieIdentificatienummer" ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-100", "comment": "ReportInformationIdentificationNumber" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-784", "comment": "ImageInformationIdentificationNumber" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-29", "comment": "uniqueID" } ] }, { "id": "DocumentReference.status", "path": "DocumentReference.status", "short": "AvailabilityStatus", "definition": "The lifecycle status of the document.", "patternCode": "current", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-3", "comment": "availabilityStatus" } ] }, { "id": "DocumentReference.type", "path": "DocumentReference.type", "short": "ProcedureType / TypeCode", "definition": "* Description of the procedure and/or the performed imaging study (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).", "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.", "alias": [ "VerrichtingType" ], "binding": { "strength": "extensible", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.133.11.1--20230808113539" }, "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-176", "comment": "ProcedureType" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-28", "comment": "typeCode" } ] }, { "id": "DocumentReference.category", "path": "DocumentReference.category", "short": "ClassCode", "definition": "The code specifying the particular kind of document.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-9", "comment": "classCode" } ] }, { "id": "DocumentReference.category.coding", "path": "DocumentReference.category.coding", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "min": 1 }, { "id": "DocumentReference.category.coding:images", "path": "DocumentReference.category.coding", "sliceName": "images", "min": 0, "max": "1", "patternCoding": { "system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1", "code": "IMAGES" }, "condition": [ "bbs-DocumentReference-1", "bbs-DocumentReference-2" ] }, { "id": "DocumentReference.category.coding:reports", "path": "DocumentReference.category.coding", "sliceName": "reports", "min": 0, "max": "1", "patternCoding": { "system": "urn:oid:1.3.6.1.4.1.19376.1.2.6.1", "code": "REPORTS" }, "condition": [ "bbs-DocumentReference-1" ] }, { "id": "DocumentReference.subject", "path": "DocumentReference.subject", "short": "Patient / PatientId", "alias": [ "Patient" ], "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ] } ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-132", "comment": "Patient" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-19", "comment": "patientId" } ] }, { "id": "DocumentReference.date", "path": "DocumentReference.date", "short": "DateTime / CreationTime", "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.", "alias": [ "DatumTijd" ], "min": 1, "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-101", "comment": "DateTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-69", "comment": "DateTime" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-11", "comment": "creationTime" } ] }, { "id": "DocumentReference.author", "path": "DocumentReference.author", "slicing": { "discriminator": [ { "type": "profile", "path": "resolve()" } ], "rules": "open" }, "short": "Author", "min": 1, "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-2", "comment": "author" } ] }, { "id": "DocumentReference.author:location", "path": "DocumentReference.author", "sliceName": "location", "short": "Location", "definition": "The healthcare center where the procedure was, is or will be carried out.", "alias": [ "Locatie" ], "min": 1, "max": "1", "type": [ { "code": "Reference", "targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ] } ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-185", "comment": "Location" } ] }, { "id": "DocumentReference.author:performer", "path": "DocumentReference.author", "sliceName": "performer", "short": "Performer", "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).", "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.", "alias": [ "Uitvoerder" ], "min": 0, "max": "*", "type": [ { "code": "Reference", "targetProfile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthProfessional-PractitionerRole" ] } ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-187", "comment": "Performer" } ] }, { "id": "DocumentReference.authenticator", "path": "DocumentReference.authenticator", "short": "LegalAuthenticator", "definition": "Represents a participant who has legally authenticated or attested the document within the author institution.", "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.", "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" ] } ], "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-17", "comment": "legalAuthenticator" } ] }, { "id": "DocumentReference.description", "path": "DocumentReference.description", "short": "Comments", "definition": "Comments associated with the document.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-4", "comment": "comments" } ] }, { "id": "DocumentReference.securityLabel", "path": "DocumentReference.securityLabel", "short": "ConfidentialityCode", "definition": "The code specifying the level of confidentiality of the document.", "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": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-10", "comment": "confidentialityCode" } ] }, { "id": "DocumentReference.content.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "short": "MimeType", "definition": "MIME type of the document.", "binding": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/elementdefinition-bindingName", "valueString": "MimeType" }, { "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" } ], "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding" } ], "strength": "required", "description": "The mime type of an attachment. Any valid mime type is allowed.", "valueSet": "http://hl7.org/fhir/ValueSet/mimetypes|4.0.1" }, "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-18", "comment": "mimeType" } ] }, { "id": "DocumentReference.content.attachment.language", "path": "DocumentReference.content.attachment.language", "short": "LanguageCode", "definition": "Specifies the human language of character data in the document. Using codes from IETF RFC 3066.", "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": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-16", "comment": "languageCode" } ] }, { "id": "DocumentReference.content.attachment.url", "path": "DocumentReference.content.attachment.url", "short": "URI", "definition": "The URI for the document.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-30", "comment": "URI" } ] }, { "id": "DocumentReference.content.attachment.size", "path": "DocumentReference.content.attachment.size", "short": "Size", "definition": "Size in bytes of the document.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-24", "comment": "size" } ] }, { "id": "DocumentReference.content.attachment.hash", "path": "DocumentReference.content.attachment.hash", "short": "Hash", "definition": "Hash of the document itself.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-14", "comment": "hash" } ] }, { "id": "DocumentReference.content.attachment.title", "path": "DocumentReference.content.attachment.title", "short": "ReportTitle / ImageTitle / Title", "definition": "* The title of the report.\n* The title of the image.\n* The title of the document.", "alias": [ "VerslagTitel", "BeeldTitel" ], "mapping": [ { "identity": "bbs-medmij-dataset-100-beta1-20250807", "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-rc1-20250919", "map": "bbs-medmij-dataelement-2", "comment": "ReportTitle" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-1", "comment": "ImageTitle" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-27", "comment": "title" } ] }, { "id": "DocumentReference.content.attachment.creation", "path": "DocumentReference.content.attachment.creation", "short": "DateTime / CreationTime", "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.", "alias": [ "DatumTijd" ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-101", "comment": "DateTime" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-69", "comment": "DateTime" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-11", "comment": "creationTime" } ] }, { "id": "DocumentReference.content.format", "path": "DocumentReference.content.format", "short": "FormatCode", "definition": "Code globally uniquely specifying the format of the document.", "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": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-13", "comment": "formatCode" } ] }, { "id": "DocumentReference.context.encounter", "path": "DocumentReference.context.encounter", "short": "ReferenceIdList", "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.", "comment": "Only Encounters on the ReferenceIdList are conveyed here, while other identifiers on that list are conveyed via `.context.related`.", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "http://hl7.org/fhir/StructureDefinition/EpisodeOfCare", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Encounter" ] } ], "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-117", "comment": "referenceIdList" } ] }, { "id": "DocumentReference.context.event", "path": "DocumentReference.context.event", "slicing": { "discriminator": [ { "type": "value", "path": "$this" } ], "rules": "open" }, "short": "EventCodeList", "definition": "This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-12", "comment": "eventCodeList" } ] }, { "id": "DocumentReference.context.event:procedureAnatomicalLocation", "path": "DocumentReference.context.event", "sliceName": "procedureAnatomicalLocation", "short": "ProcedureAnatomicalLocation / Location", "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.", "alias": [ "VerrichtingAnatomischeLocatie", "Locatie" ], "min": 0, "max": "1", "type": [ { "code": "CodeableConcept", "profile": [ "http://nictiz.nl/fhir/StructureDefinition/nl-core-AnatomicalLocation" ] } ], "binding": { "strength": "required", "valueSet": "http://decor.nictiz.nl/fhir/ValueSet/2.16.840.1.113883.2.4.3.11.60.106.11.19--20240205123345" }, "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-178", "comment": "ProcedureAnatomicalLocation" }, { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-179", "comment": "Location" } ] }, { "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": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-180", "comment": "Laterality" } ] }, { "id": "DocumentReference.context.event:modality", "path": "DocumentReference.context.event", "sliceName": "modality", "short": "Modality", "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.", "comment": "For an image or series of images the modalities SHALL be specified.", "alias": [ "Modaliteit" ], "min": 0, "max": "*", "condition": [ "bbs-DocumentReference-2" ], "binding": { "extension": [ { "extension": [ { "url": "key", "valueId": "bbs-DocumentReference-binding-modality-1" }, { "url": "purpose", "valueCode": "minimum" }, { "url": "valueSet", "valueCanonical": "http://medmij.nl/fhir/ValueSet/Modality" } ], "url": "http://hl7.org/fhir/tools/StructureDefinition/additional-binding" } ], "strength": "required", "valueSet": "http://medmij.nl/fhir/ValueSet/ModalityCombined" }, "mapping": [ { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-5", "comment": "Modality" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-5", "comment": "Modality" } ] }, { "id": "DocumentReference.context.period", "path": "DocumentReference.context.period", "min": 1 }, { "id": "DocumentReference.context.period.start", "path": "DocumentReference.context.period.start", "short": "ProcedureStartDate / ServiceStartTime", "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.", "alias": [ "VerrichtingStartDatum" ], "min": 1, "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-174", "comment": "ProcedureStartDate" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-22", "comment": "serviceStartTime" } ] }, { "id": "DocumentReference.context.period.end", "path": "DocumentReference.context.period.end", "short": "ProcedureEndDate / ServiceStopTime", "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.", "alias": [ "VerrichtingEindDatum" ], "mapping": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-175", "comment": "ProcedureEndDate" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-23", "comment": "serviceStopTime" } ] }, { "id": "DocumentReference.context.facilityType", "path": "DocumentReference.context.facilityType", "short": "OrganizationType / HealthcareFacilityTypeCode", "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.", "alias": [ "OrganisatieType" ], "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": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-546", "comment": "OrganizationType" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-31", "comment": "healthcareFacilityTypeCode" } ] }, { "id": "DocumentReference.context.practiceSetting", "path": "DocumentReference.context.practiceSetting", "short": "DepartmentSpecialty / PracticeSettingCode", "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).", "alias": [ "AfdelingSpecialisme" ], "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": [ { "identity": "bbs-dataset-100-alpha2-20240208", "map": "bbs-dataelement-524", "comment": "DepartmentSpecialty" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-20", "comment": "practiceSettingCode" } ] }, { "id": "DocumentReference.context.sourcePatientInfo", "path": "DocumentReference.context.sourcePatientInfo", "short": "SourcePatientId / SourcePatientInfo", "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.", "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "http://nictiz.nl/fhir/StructureDefinition/nl-core-Patient" ] } ], "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-25", "comment": "sourcePatientId" }, { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-26", "comment": "sourcePatientInfo" } ] }, { "id": "DocumentReference.context.related", "path": "DocumentReference.context.related", "slicing": { "discriminator": [ { "type": "value", "path": "identifier.type" } ], "rules": "open" }, "short": "ReferenceIdList", "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.", "comment": "Encounters on the ReferenceIdList are conveyed via `.context.encounter`.", "mapping": [ { "identity": "ihexds-dataset-2024-20220712", "map": "ihexds-dataelement-117", "comment": "referenceIdList" } ] }, { "id": "DocumentReference.context.related:accessionNumber", "path": "DocumentReference.context.related", "sliceName": "accessionNumber", "min": 0, "max": "1" }, { "id": "DocumentReference.context.related:accessionNumber.identifier", "path": "DocumentReference.context.related.identifier", "short": "AccessionNumber", "definition": "A locally unique record number in the RIS that identifies the imaging procedure request.", "alias": [ "AccessionNumber" ], "min": 1, "mapping": [ { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-3", "comment": "AccessionNumber" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-3", "comment": "AccessionNumber" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.type", "path": "DocumentReference.context.related.identifier.type", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "urn:ietf:rfc:3986", "code": "urn:ihe:iti:xds:2013:accession" } ] } }, { "id": "DocumentReference.context.related:accessionNumber.identifier.system", "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` SHOULD 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": [ { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-7", "comment": "AssigningAuthority (implicit, main mapping is on .context.related[accessionNumber].identifier.assigner)" } ] }, { "id": "DocumentReference.context.related:accessionNumber.identifier.value", "path": "DocumentReference.context.related.identifier.value", "min": 1 }, { "id": "DocumentReference.context.related:accessionNumber.identifier.assigner", "path": "DocumentReference.context.related.identifier.assigner", "short": "AssigningAuthority", "definition": "Assigning authority that issued the Accession Number.", "alias": [ "UitgevendeInstantie" ], "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Organization", "http://nictiz.nl/fhir/StructureDefinition/nl-core-HealthcareProvider-Organization" ] } ], "mapping": [ { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-7", "comment": "AssigningAuthority" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID", "path": "DocumentReference.context.related", "sliceName": "studyInstanceUID", "min": 0, "max": "1" }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier", "path": "DocumentReference.context.related.identifier", "short": "StudyInstanceUID", "definition": "The globally unique DICOM identifier of the imaging study upon which the imaging report is based, assigned by the modality or PACS.", "alias": [ "StudyInstanceUID" ], "min": 1, "mapping": [ { "identity": "bbs-medmij-dataset-100-beta1-20250807", "map": "bbs-medmij-dataelement-4", "comment": "StudyInstanceUID" }, { "identity": "bbs-medmij-dataset-100-rc1-20250919", "map": "bbs-medmij-dataelement-4", "comment": "StudyInstanceUID" } ] }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.type", "path": "DocumentReference.context.related.identifier.type", "min": 1, "patternCodeableConcept": { "coding": [ { "system": "urn:ietf:rfc:3986", "code": "urn:ihe:iti:xds:2016:studyInstanceUID" } ] } }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.system", "path": "DocumentReference.context.related.identifier.system", "min": 1, "patternUri": "urn:dicom:uid" }, { "id": "DocumentReference.context.related:studyInstanceUID.identifier.value", "path": "DocumentReference.context.related.identifier.value", "comment": "As the Study Instance UID is a DICOM UID, its value SHALL be prefixed with _urn:oid:_.", "min": 1, "constraint": [ { "key": "bbs-DocumentReference-3", "severity": "error", "human": "Each DICOM UID value is a proper OID.", "expression": "$this.startsWith('urn:oid:')", "source": "http://medmij.nl/fhir/StructureDefinition/bbs-DocumentReference" } ] } ] } }