NDHM (R4), Published and maintained by NRCeS for NHA.
This version is based on the NDHM Health Data Interchange Specifications 1.0 and updated periodically.

• Narrative Content
• Detailed Descriptions
• Mappings
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Mappings for the StructureDefinition-OPConsultRecord Profile.

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

OPConsultRecord
Composition	Event
identifier	Event.identifier
status	Event.status
type	Event.code
category	Event.subject
encounter	Event.context
date	Event.occurrence[x]
author	Event.performer

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

OPConsultRecord
Composition	Entity. Role, or Act, Document[classCode="DOC" and moodCode="EVN" and isNormalAct()]
text	Act.text?
contained	N/A
extension	N/A
modifierExtension	N/A
identifier	Document.id / Document.setId
status	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("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and moodCode="EVN" and domainMember("ReviseComposition", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
type	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
category	.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
subject	.participation[typeCode="SBJ"].role[typeCode="PAT"]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
encounter	unique(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"]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
title	./title
confidentiality	.confidentialityCode
attester	.participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
id	n/a
extension	n/a
modifierExtension	N/A
mode	unique(./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
id	n/a
extension	n/a
modifierExtension	N/A
code	.outboundRelationship.typeCode
target[x]	.target[classCode="DOC", moodCode="EVN"].id
event	outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
id	n/a
extension	n/a
modifierExtension	N/A
code	.code
period	.effectiveTime
detail	.outboundRelationship[typeCode="SUBJ"].target
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (ChiefComplaints)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=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]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (Allergies)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (MedicalHistory)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (FamilyHistory)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (InvestigationAdvice)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (Medications)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (FollowUp)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (Procedure)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
section (DocumentReference)	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]
id	n/a
extension	n/a
modifierExtension	N/A
title	./title
code	./code
id	n/a
extension	n/a
coding	union(., ./translation)
id	n/a
extension	n/a
system	./codeSystem
version	./codeSystemVersion
code	./code
display	CV.displayName
userSelected	CD.codingRationale
text	./originalText[mediaType/code="text/plain"]/data
author	.participation[typeCode="AUT"].role[classCode="ASSIGNED"]
text	.text
mode	.outBoundRelationship[typeCode=COMP].target[classCode=OBS"].value
orderedBy	.outboundRelationship[typeCode=COMP].sequenceNumber > 1
entry	.outboundRelationship[typeCode=COMP] or .participation[typeCode=SBJ]
id	n/a
extension	n/a
reference	N/A
type	N/A
identifier	.identifier
display	N/A
emptyReason	.inboundRelationship[typeCode=SUBJ,code<ListEmptyReason].value[type=CD]
section	./outboundRelationship[typeCode="COMP" and isNormalActRelationship()]/target[moodCode="EVN" and classCode="DOCSECT" and isNormalAct]

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

OPConsultRecord
Composition	ClinicalDocument
identifier	.setId
status	n/a
type	.code
category	n/a
subject	.recordTarget
encounter	.componentOf.encompassingEncounter
date	.effectiveTime
author	.author.assignedAuthor
title	.title
confidentiality	.confidentialityCode
attester	.authenticator/.legalAuthenticator
mode	implied by .authenticator/.legalAuthenticator
time	.authenticator.time
party	.authenticator.assignedEnttty
custodian	.custodian.assignedCustodian
relatesTo	.relatedDocument
code	.relatedDocument.typeCode
target[x]	.relatedDocument.id
event	.documentationOf.serviceEvent
code	.code
period	.effectiveTime
detail	n/a
section	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (ChiefComplaints)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (PhysicalExamination)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (Allergies)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (MedicalHistory)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (FamilyHistory)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (InvestigationAdvice)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (Medications)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (FollowUp)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (Procedure)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section
section (DocumentReference)	.component.structuredBody.component.section
title	.title
code	.code
author	.author.assignedAuthor
focus	.subject? (CDA did not differentiate between subject and focus)
text	.text
mode	n/a
orderedBy	n/a
entry	.entry
emptyReason	n/a
section	.component.section

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

OPConsultRecord
Composition	when described by DocumentReference
identifier	DocumentReference.masterIdentifier
status	DocumentReference.status
type	DocumentReference.type
category	DocumenttReference.category
subject	DocumentReference.subject
encounter	DocumentReference.context.encounter
date	DocumentReference.content.attachment.date, DocumentReference.created
author	DocumentReference.agent
title	DocumentReference.description, DocumentReference.content.attachment.title
confidentiality	DocumentReference.securityLabel
attester	DocumentReference.authenticator
custodian	DocumentReference.custodian
relatesTo	DocumentReference.relatesTo
code	DocumentReference.relatesTo.code
target[x]	DocumentReference.relatesTo.target
event	DocumentReference.event
code	DocumentReference.event.code
period	DocumentReference.event.period

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

OPConsultRecord
Composition
identifier	FiveWs.identifier
status	FiveWs.status
type	FiveWs.class
category	FiveWs.class
subject	FiveWs.subject[x], FiveWs.subject
encounter	FiveWs.context
date	FiveWs.done[x]
author	FiveWs.author
attester
party	FiveWs.witness
section
author	FiveWs.author
mode	FiveWs.class
section (ChiefComplaints)
author	FiveWs.author
mode	FiveWs.class
section (PhysicalExamination)
author	FiveWs.author
mode	FiveWs.class
section (Allergies)
author	FiveWs.author
mode	FiveWs.class
section (MedicalHistory)
author	FiveWs.author
mode	FiveWs.class
section (FamilyHistory)
author	FiveWs.author
mode	FiveWs.class
section (InvestigationAdvice)
author	FiveWs.author
mode	FiveWs.class
section (Medications)
author	FiveWs.author
mode	FiveWs.class
section (FollowUp)
author	FiveWs.author
mode	FiveWs.class
section (Procedure)
author	FiveWs.author
mode	FiveWs.class
section (DocumentReference)
author	FiveWs.author
mode	FiveWs.class