醫查實作指引
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Resource Profile: CompositionDischargeSummaryIMRI - Mappings

Active as of 2024-08-12

Mappings for the composition-dischargesummary-imri resource profile.

Mappings for Workflow Pattern (http://hl7.org/fhir/workflow)

CompositionDischargeSummaryIMRI
CompositionEvent
   identifierEvent.identifier
   statusEvent.status
   encounterEvent.context
   dateEvent.occurrence[x]
   authorEvent.performer

Mappings for RIM Mapping (http://hl7.org/v3)

CompositionDischargeSummaryIMRI
CompositionEntity. Role, or Act, Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
   textAct.text?
   containedN/A
   identifierDocument.id / Document.setId
   statusinterim: .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("ReviseComposition", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
   typen/a, CD
   categoryn/a, CD
   subject.participation[typeCode="SBJ"].role[typeCode="PAT"]
   encounterunique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
   date.effectiveTime[type="TS"]
   author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
   title./title
   confidentiality.confidentialityCode
   attester.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
      idn/a
      extensionn/a
      modifierExtensionN/A
      modeunique(./modeCode)
      time./time[type="TS" and isNormalDatatype()]
      party./role[classCode="ASSIGNED" and isNormalRole]/player[determinerCode="INST" and classCode=("DEV", "PSN") and isNormalEntity()] or ./role[classCode="ASSIGNED" and isNormalRole and not(player)]/scoper[determinerCode="INST" and classCode="ORG" and isNormalEntity()]
   custodian.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
   relatesTo.outboundRelationship
      idn/a
      extensionn/a
      modifierExtensionN/A
      code.outboundRelationship.typeCode
      target[x].target[classCode="DOC", moodCode="EVN"].id
   eventoutboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
      idn/a
      extensionn/a
      modifierExtensionN/A
      coden/a, CD
      period.effectiveTime
      detail.outboundRelationship[typeCode="SUBJ"].target
   section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (Impression)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (DischargeDiagnosis)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (CancerStaging)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (ChiefComplaint)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (PresentIllness)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (PhysicalExamination)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (LaboratoryData)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (ImagingStudy)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (PathologyReport)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (SurgicalMethod)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (HospitalCourse)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (ComorbiditesAndOrComlications)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
   section (InstructionsOnDischarge)./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
      idn/a
      extensionn/a
      modifierExtensionN/A
      title./title
      coden/a, CD
      author.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
      text.text
      mode.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
      orderedByn/a, CD
      entry.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
      emptyReasonn/a, CD
      section./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]

Mappings for CDA (R2) (http://hl7.org/v3/cda)

CompositionDischargeSummaryIMRI
CompositionClinicalDocument
   identifier.setId
   statusn/a
   subject.recordTarget
   encounter.componentOf.encompassingEncounter
   date.effectiveTime
   author.author.assignedAuthor
   title.title
   confidentiality.confidentialityCode
   attester.authenticator/.legalAuthenticator
      modeimplied by .authenticator/.legalAuthenticator
      time.authenticator.time
      party.authenticator.assignedEnttty
   custodian.custodian.assignedCustodian
   relatesTo.relatedDocument
      code.relatedDocument.typeCode
      target[x].relatedDocument.id
   event.documentationOf.serviceEvent
      period.effectiveTime
      detailn/a
   section.component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (Impression).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (DischargeDiagnosis).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (CancerStaging).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (ChiefComplaint).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (PresentIllness).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (PhysicalExamination).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (LaboratoryData).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (ImagingStudy).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (PathologyReport).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (SurgicalMethod).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (HospitalCourse).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (ComorbiditesAndOrComlications).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section
   section (InstructionsOnDischarge).component.structuredBody.component.section
      title.title
      author.author.assignedAuthor
      focus.subject? (CDA did not differentiate between subject and focus)
      text.text
      moden/a
      entry.entry
      section.component.section

Mappings for FHIR DocumentReference (http://hl7.org/fhir/documentreference)

CompositionDischargeSummaryIMRI
Compositionwhen described by DocumentReference
   identifierDocumentReference.masterIdentifier
   statusDocumentReference.status
   subjectDocumentReference.subject
   encounterDocumentReference.context.encounter
   dateDocumentReference.content.attachment.date, DocumentReference.created
   authorDocumentReference.agent
   titleDocumentReference.description, DocumentReference.content.attachment.title
   confidentialityDocumentReference.securityLabel
   attesterDocumentReference.authenticator
   custodianDocumentReference.custodian
   relatesToDocumentReference.relatesTo
      codeDocumentReference.relatesTo.code
      target[x]DocumentReference.relatesTo.target
   eventDocumentReference.event
      periodDocumentReference.event.period

Mappings for FiveWs Pattern Mapping (http://hl7.org/fhir/fivews)

CompositionDischargeSummaryIMRI
Composition
   identifierFiveWs.identifier
   statusFiveWs.status
   subjectFiveWs.subject[x], FiveWs.subject
   encounterFiveWs.context
   dateFiveWs.done[x]
   authorFiveWs.author
   attester
      partyFiveWs.witness
   section
      authorFiveWs.author
      modeFiveWs.class
   section (Impression)
      authorFiveWs.author
      modeFiveWs.class
   section (DischargeDiagnosis)
      authorFiveWs.author
      modeFiveWs.class
   section (CancerStaging)
      authorFiveWs.author
      modeFiveWs.class
   section (ChiefComplaint)
      authorFiveWs.author
      modeFiveWs.class
   section (PresentIllness)
      authorFiveWs.author
      modeFiveWs.class
   section (PhysicalExamination)
      authorFiveWs.author
      modeFiveWs.class
   section (LaboratoryData)
      authorFiveWs.author
      modeFiveWs.class
   section (ImagingStudy)
      authorFiveWs.author
      modeFiveWs.class
   section (PathologyReport)
      authorFiveWs.author
      modeFiveWs.class
   section (SurgicalMethod)
      authorFiveWs.author
      modeFiveWs.class
   section (HospitalCourse)
      authorFiveWs.author
      modeFiveWs.class
   section (ComorbiditesAndOrComlications)
      authorFiveWs.author
      modeFiveWs.class
   section (InstructionsOnDischarge)
      authorFiveWs.author
      modeFiveWs.class