Medical Document Binding to XDS, XDM and XDR
Medical Document Binding to XDS, XDM and XDR
This binding defines a transformation that generates metadata for the XDSDocumentEntry element of appropriate transactions from the XDS, XDM and XDR profiles given a medical document and information from other sources. The medical document refers to the document being stored in a repository that will be referenced in the registry. The other sources of information include the configuration of the Document Source actor, the Affinity Domain, the site or facility, local agreements, other documents in the registry/repository, and this Content Profile.
XDSDocumentEntry Metadata
| XDSDocumentEntry Attribute | Optional? | Source Type | Source/ Value |
|---|---|---|---|
| authorSpecialty This metadata element should be based on a detailed defined classification system for healthcare providers such as those found in SNOMED-CT, or the HIPPA Healthcare Provider Taxonomy. |
R2 | ||
| authorInstitution | R2 | SA | /ClinicalDocument/author /assignedAuthor /representedOrganization/name |
| authorPerson The author can be formatted using the following XPath expression, where $person in the expression below represents the author. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given,"^", $person/assignedPerson/name/middle,"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", $person/assignedPerson/name/degree,"^^&", $person/id/@root,"&ISO" ) |
R2 | SAT | $person <= /ClinicalDocument/author |
| classCode 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). |
R | CADT | Must be consistent with /ClinicalDocument/code/@code |
| classCodeDisplayName DisplayName of the classCode derived. Derived from a mapping of /ClinicalDocument/code/@code to the appropriate Display Name based on the Type of Service. |
R | CADT | Must be Consitent with /ClinicalDocument/code/@code |
| confidentialityCode Derived from a mapping of /ClinicalDocument/confidentialityCode/@code to an Affinity Domain specified coded value and coding system. When using the BPPC profile, the confidentialyCode may also be obtained from the <authorization> element. |
R | CADT | /ClinicalDocument/confidentialityCode/@code -AND/OR- |
| creationTime | R | SA | /ClinicalDocument/effectiveTime |
| eventCodeList These values express a collection of keywords that may be relevant to the consumer of the documents in the registry. |
O |
CADT | |
| eventCodeDisplayNameList These are the display names for the collection of keywords described above. |
R (if event Code is valued) |
CADT | |
| formatCode The format code shall be the OID associated with the template identifier used to identify the content module that the document conforms to. See PCC TF-2:5.1.2 for a list of values that can be used as format codes. |
R | FM | /ClinicalDocument/templateId |
| healthcareFacilityTypeCode A fixed value assigned to the Document Source and configured form a set of Affinity Domain defined values. |
R |
O | Must be concistent with /clinicalDocument/code |
| healthcareFacility TypeCodeDisplay Name |
R | O | Must be concistent with /clinicalDocument/code |
| intendedRecipient The intendedRecipient can be formatted using the following XPath expression, where $person in the expression below represents the intendedRecipient. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given,"^", $person/assignedPerson/name/middle,"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", $person/assignedPerson/name/degree,"^^&", $person/id/@root,"&ISO" ) |
R2 | SAT | $person <= /ClinicalDocument/intendedRecipient |
| languageCode | R | SA | /ClinicalDocument/languageCode |
| legalAuthenticator The legalAuthenticator can be formatted using the following XPath expression, where $person in the expression below represents the legalAuthenticator. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given,"^", $person/assignedPerson/name/middle,"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", $person/assignedPerson/name/degree,"^^&", $person/id/@root,"&ISO" ) |
O | SAT | $person <= /ClinicalDocument/ legalAuthenticator |
| mimeType | R | FM | text/xml |
| parentDocumentRelationship | R (when applicable) |
SA | /ClinicalDocument/relatedDocument/@typeCode |
| parentDocumentId The parentDocumentId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier. concat($docID/@root,"^", $docID/@extension) |
R (when parent Document Relationship is present) |
SAT | $docID <= /ClinicalDocument/ relatedDocument/parentDocument/ id |
| patientId The patientId can be formatted using the following XPath expression, where $patID in the expression below represents the appropriate identifier. concat($patID/@extension,"^^^&", $patID/@root, "&ISO") |
R | SAT | $patID <= /ClinicalDocument/recordTarget/ patientRole/id |
| practiceSettingCode This elements 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. |
R |
CAD | |
| practiceSettingCodeDisplayName This element shall contain the display names associated with the codes described above. |
R | CAD | |
| serviceStartTime | R2 | SA | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value |
| serviceStopTime | R2 | SA | /ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value |
| sourcePatientId | R | DS | |
| sourcePatientInfo | R | DS | |
| Title | O | SA | /ClinicalDocument/title |
| typeCode | R |
SA | /ClinicalDocument/code/@code |
| typeCodeDisplay Name |
R | SA | /ClinicalDocument/code/@displayName |
| uniqueId The uniqueId can be formatted using the following XPath expression, where $docID in the expression below represents the identifier. concat($docID/@root,"^", $docID/@extension) |
R | SAT | $docID <= /ClinicalDocument/id |
XDSSubmissionSet Metadata
| XDSSubmissionSet Attribute | Optional? | Source Type | Source/ Value |
|---|---|---|---|
| authorDepartment This metadata element should be based on a detailed defined classification system for healthcare providers such as those found in SNOMED-CT, or the HIPPA Healthcare Provider Taxonomy. |
R2 | CAD | |
| authorInstitution | R2 | SA | /ClinicalDocument/author/assignedAuthor /representedOrganization/name |
| authorPerson The author can be formatted using the following XPath expression, where $person in the expression below represents the author. concat( $person/id/@extension,"^", $person/assignedPerson/name/family,"^", $person/assignedPerson/name/given,"^", $person/assignedPerson/name/middle,"^", $person/assignedPerson/name/suffix,"^", $person/assignedPerson/name/prefix,"^", $person/assignedPerson/name/degree,"^^&", $person/id/@root,"&ISO" ) |
R2 | SAT | $person <= /ClinicalDocument/author |
| comments | R2 | string(//section[@code='42349-1']/text) This is the reason for referral if present. | |
| contentTypeCode | R | CAD | |
| contentTypeCodeDisplayName | R | CAD | |
| patientId The patientId can be formatted using the following XPath expression, where $patID in the expression below represents the appropriate identifier. concat($patID/@extension,"^^^&", $patID/@root, "&ISO") |
R | SAT | $patID <= /ClinicalDocument/recordTarget /patientRole/id |
| sourceId | R | DS | |
| submissionTime | R | DS | |
| uniqueId | R |
Use of XDS Submission Set
This content format uses the XDS Submission Set to create a package of information to send from one provider to another. All documents referenced by the Medical Summary in this Package must be in the submission set.
Use of XDS Folders
No specific requirements identified.
Configuration
This Medical Summary Content Profile requires that Content Creators and Content Consumers using these documents be configured with institution and other specific attributes or parameters. Implementers should be aware of these requirements to make such attributes easily configurable. There shall be a mechanism for the publishing and distribution of style sheets used to view medication summaries (See PCC TF-2: 5.4.1.1.2.1).