Inera Core Implementation Guide
0.2.0 - ci-build
Sweden
Inera Core Implementation Guide - Local Development build (v0.2.0) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions
| Official URL: https://inera.se/fhir/core/ConceptMap/getcaredocumentation-tkb-to-documentreference | Version: 0.2.0 | |||
| Draft as of 2025-11-24 | Computable Name: ConceptMapGetCareDocumentationTKBToDocumentReference | |||
Complete mapping from GetCareDocumentation TKB service to FHIR DocumentReference, Composition, and Provenance resources
Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to DocumentReference
Group 1 Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to Bundle
| Source Code | Relationship | Target Code | Comment |
| patientId (Query parameter: Patient ID filter) | (not mapped) | NOT MAPPED. Used as search parameter: GET /DocumentReference?subject=Patient/191212121212 | |
| careUnitHSAid (Query parameter: Filter by care unit HSA-ID) | (not mapped) | NOT MAPPED. Used as search parameter: GET /DocumentReference?custodian.identifier=https://hsaid.se|SE2321000016-A001 | |
| sourceSystemHSAid (Query parameter: Filter by source system) | (not mapped) | NOT MAPPED. Used as search parameter or routing to specific system | |
| timePeriod (Query parameter: Time period filter (from-to)) | (not mapped) | NOT MAPPED. Used as search parameter: GET /DocumentReference?date=ge2025-01-01&date=le2025-12-31 | |
| careContactId (Query parameter: Filter by specific care contact) | (not mapped) | NOT MAPPED. Used as search parameter: GET /DocumentReference?encounter=Encounter/{id} | |
Group 2 Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to DocumentReference
| Source Code | Relationship | Target Code | Comment |
| careDocumentation.careDocumentationHeader.documentId (Document ID (unique business identifier)) | is equivalent to | identifier | Unique document identifier within source system. Must be persistent across TKB versions. System derived from sourceSystemHSAid. |
| careDocumentation.careDocumentationHeader.patientId (Patient ID (personnummer/samordningsnummer/reservnummer)) | is equivalent to | subject | Reference to Patient with Swedish national identifier. OID 1.2.752.129.2.1.3.1 (personnummer), 1.2.752.129.2.1.3.3 (samordningsnummer) |
| careDocumentation.careDocumentationHeader.approvedForPatient (Approved for patient access (true/false)) | is equivalent to | meta.security | If false, add security label NOPATIENT to restrict patient access (menprövningsflagga). See tkb-header-mapping documentation. |
| careDocumentation.careDocumentationBody.documentType (Document type code (vårdkontaktanteckning, läkarintyg, etc.)) | is equivalent to | type | Swedish document type. Use LOINC document codes or Swedish national codes. Examples: 11506-3 (progress note), 18842-5 (discharge summary), 57133-1 (referral note) |
| careDocumentation.careDocumentationBody.documentCategory (Document category (high-level classification)) | is equivalent to | category | High-level category. Use US Core categories: clinical-note, summary-of-episode-note, discharge-summary, etc. |
| careDocumentation.careDocumentationBody.documentStatus (Document status (preliminary, final, amended, entered-in-error)) | is related to | status | Maps to DocumentReference.status (current|superseded|entered-in-error) and docStatus (preliminary|final|amended|corrected|appended) |
| careDocumentation.careDocumentationBody.documentTitle (Document title/description) | is equivalent to | description | Human-readable title. Also used in Composition.title. |
| careDocumentation.careDocumentationHeader.documentTime (Document creation timestamp) | is equivalent to | date | When document was created/indexed. Note: TKB may use authorTime instead for some documents. |
| careDocumentation.careDocumentationHeader.careContactId (Care contact ID (encounter context)) | is equivalent to | context.encounter | Reference to Encounter resource. Links document to care contact. |
| careDocumentation.careDocumentationBody.content (Document content (binary or referenced)) | is equivalent to | content.attachment | For unstructured content (PDF, XHTML, XML): use attachment.data (base64) or attachment.url. Set contentType (application/pdf, text/html, etc.) |
| careDocumentation.careDocumentationBody.format (Document format code) | is equivalent to | content.format | Format code from http://ihe.net/fhir/ValueSet/IHE.FormatCode.codesystem or Swedish format codes |
| careDocumentation.careDocumentationBody.mimeType (MIME type (application/pdf, text/html, etc.)) | is equivalent to | content.attachment.contentType | MIME type: application/pdf, text/html, application/fhir+xml, application/fhir+json, etc. |
| careDocumentation.careDocumentationHeader.nullified (Document nullified flag) | is equivalent to | status | If nullified=true, set status=entered-in-error. Use Provenance resource to capture nullifiedReason. |
| careDocumentation.careDocumentationHeader.nullifiedReason (Reason for nullification) | is equivalent to | Provenance.reason | Reason for nullification/retraction. Map to Provenance resource with activity=DELETE or UPDATE, reason containing the nullification reason text. |
Group 3 Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to Composition
| Source Code | Relationship | Target Code | Comment |
| careDocumentation.careDocumentationHeader.documentId (Document ID) | is equivalent to | identifier | Same identifier as DocumentReference for linking |
| careDocumentation.careDocumentationBody.documentStatus (Composition status) | is related to | status | Composition.status: preliminary|final|amended|entered-in-error. Maps from TKB documentStatus. |
| careDocumentation.careDocumentationBody.documentType (Composition type) | is equivalent to | type | Same type code as DocumentReference.type. LOINC or Swedish document type codes. |
| careDocumentation.careDocumentationBody.documentCategory (Composition category) | is equivalent to | category | High-level categorization matching DocumentReference.category |
| careDocumentation.careDocumentationHeader.patientId (Patient ID) | is equivalent to | subject | Reference to Patient resource |
| careDocumentation.careDocumentationHeader.careContactId (Care contact/encounter context) | is equivalent to | encounter | Reference to Encounter when document created during care contact |
| careDocumentation.careDocumentationHeader.documentTime (Composition date) | is equivalent to | date | Composition edit/change time. May differ from authorTime. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional (Document author (healthcare professional)) | is equivalent to | author | Reference to Practitioner. Can have multiple authors. Also mapped to Provenance for full metadata. |
| careDocumentation.careDocumentationBody.documentTitle (Composition title) | is equivalent to | title | Human-readable document title |
| careDocumentation.careDocumentationHeader.legalAuthenticator (Legal authenticator (attester)) | is equivalent to | attester | Composition.attester with mode=#legal, time=signatureTime, party=Reference(Practitioner). Also creates Provenance.signature. |
| careDocumentation.careDocumentationBody.custodian (Document custodian (care provider organization)) | is equivalent to | custodian | Reference to Organization (vårdgivare) responsible for document |
| careDocumentation.careDocumentationBody.section (Document sections (reason for visit, assessment, plan, etc.)) | is equivalent to | section | Composition.section with code, title, text (narrative), and entry (references to resources). Common LOINC section codes: 10154-3 (chief complaint), 10164-2 (history), 29545-1 (physical exam), 51847-2 (assessment), 18776-5 (plan) |
Group 4 Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to Provenance
| Source Code | Relationship | Target Code | Comment |
| careDocumentation.careDocumentationHeader.sourceSystemHSAid (Source system HSA-ID) | is equivalent to | entity.what | HSA-ID of source system. Also mapped to DocumentReference.meta.source as https://hsaid.se/{HSA-ID}. Provenance.entity.role=source. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.authorTime (Author time (registration timestamp)) | is equivalent to | recorded | When document information was recorded. Also mapped to DocumentReference.meta.lastUpdated. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalHSAid (Healthcare professional HSA-ID) | is equivalent to | agent.who | Reference to Practitioner with HSA-ID. Provenance.agent.type=author. Also in Composition.author and DocumentReference.author. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalName (Healthcare professional name) | is equivalent to | agent.who.display | Display name. Full Practitioner resource should have structured name. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalRoleCode (Healthcare professional role/befattning) | is related to | agent.role | Professional role (befattning). Use KV Befattning (OID 1.2.752.129.2.2.1.4). Map to Provenance.agent.role or store in Practitioner.qualification. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalOrgUnit (Organization unit (where professional works)) | is equivalent to | agent.onBehalfOf | Reference to Organization (organizational unit). Full details (HSA-ID, name, telecom, address, location) in Organization resource. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalCareUnitHSAid (Care unit HSA-ID (vårdenhet)) | is equivalent to | entity.what | HSA-ID for care unit. Reference to Organization. Part of PDL hierarchy. Also in DocumentReference.custodian. |
| careDocumentation.careDocumentationHeader.accountableHealthcareProfessional.healthcareProfessionalCareGiverHSAid (Care provider HSA-ID (vårdgivare)) | is equivalent to | entity.what | HSA-ID for care provider. Top-level organization in PDL hierarchy. Reference to Organization. |
| careDocumentation.careDocumentationHeader.legalAuthenticator.signatureTime (Signature timestamp) | is equivalent to | signature.when | When document was digitally signed. Also in Composition.attester.time. |
| careDocumentation.careDocumentationHeader.legalAuthenticator.legalAuthenticatorHSAid (Legal authenticator HSA-ID) | is equivalent to | signature.who | Reference to Practitioner who signed document. Provenance.agent.type=legal. |
| careDocumentation.careDocumentationHeader.legalAuthenticator.signatureData (Digital signature (cryptographic)) | is equivalent to | signature.data | Base64 encoded signature. Set sigFormat (application/jose, application/xmldsig+xml, etc.). Type code: 1.2.840.10065.1.12.1.1 (Author's Signature) |
Group 5 Mapping from https://rivta.se/domains/clinicalprocess/healthcond/description/GetCareDocumentationResponder/2 to Bundle
| Source Code | Relationship | Target Code | Comment |
| result.resultCode (Result code (OK, INFO, ERROR)) | (not mapped) | NOT MAPPED to resources. HTTP status: OK→200, INFO→200 with warnings, ERROR→4xx/5xx. Bundle-level OperationOutcome for details. | |
| result.errorCode (Error code) | (not mapped) | NOT MAPPED to resources. Use in OperationOutcome.issue.code when resultCode=ERROR. | |
| result.logId (Log ID (UUID for troubleshooting)) | (not mapped) | NOT MAPPED to resources. Use in OperationOutcome.issue.diagnostics or X-Request-Id header. | |
| result.message (Result message) | (not mapped) | NOT MAPPED to resources. User-facing message in OperationOutcome.issue.diagnostics. | |