T.2 Document Terminology

These concise definitions establish the language used in Chapter 1 and Appendix A. The detailed explanations, examples, and code catalog are in Appendix A.

Term	Meaning and use
Source Form	The human-readable representation of the source-authored document information preserved in an exchanged clinical document. It establishes the content and authorship boundaries of that representation.
Minimally Structured Document	A standardized clinical document that preserves its human-readable Source Form and includes the dependable structure required by the applicable document and exchange specifications.
Progressive Structuring	A methodology for progressively enriching a document’s computable representation while preserving its source information, attribution, and context.
Information Collection Scope	The boundary that establishes which information belongs to a collection, such as an encounter, an established episode, or a point-in-time patient summary.
Species	The Document Type dimension: the specific semantic kind of clinical information collection.
Genus	The Document Template/Profile dimension: the asserted structural and conformance model.
Family	The Document Category dimension: the broader semantic group or groups to which a document belongs.
Pregnancy History	The guide’s label for LOINC 10162-6. Section use and broader document-classification use are distinct applications; Appendix A lists the use-case mappings.
Document Type	The specific semantic kind of clinical document: what information collection it represents. This is the Species dimension. Use Document Type in conceptual prose and the exact standard field name in encoding requirements.
Document Category	A broader semantic grouping of documents for discovery and workflow. This is the Family dimension; a document may belong to multiple categories. Its coded representation depends on the applicable standard and exchange policy.
Document Template/Profile	The asserted structural and conformance requirements for a document, corresponding to the Genus dimension. It is distinct from Document Type and Document Category. A format code describes a declared format/profile convention; it is not the full template definition.
Document Lifecycle	The progression and history of a document’s preparation, completion, amendment, correction, replacement, or invalidation. It is separate from the lifecycle of a Direct message or MAP transaction.
Document Status	The asserted clinical or authoring state of a particular document version, interpreted under its source specification. It is distinct from metadata availability, transport disposition, and structured payload acceptance.
On-Demand Document	An on-demand document is assembled at the time it is requested/needed, but the effective time of the document is tied to the clinically relevant time of the document’s context, for example a specific encounter or episode of care.
Dynamically Generated Document	In this guide, a dynamically generated document takes the current context of available information to include in the document. Its clinical effective time is now.

Document Classification Field Crosswalk

Use the conceptual terms below in prose. Use exact field names when specifying population rules. These mappings identify semantic roles; they do not establish interchangeable bindings or cardinalities.

Standard representation	Document Type	Document Category
IHE XD DocumentEntry	DocumentEntry.typeCode	DocumentEntry.classCode carries the exchange-defined broad classification; align it with Document Category only where that mapping is declared.
CDA	ClinicalDocument/code	ClinicalDocument/sdtc:category (urn:hl7-org:sdtc); not ClinicalDocument/@classCode, whose fixed DOCCLIN value identifies the RIM class.
FHIR R4 Composition	Composition.type	Composition.category
FHIR R4 DocumentReference	DocumentReference.type	DocumentReference.category

Document-level CDA templateId and applicable FHIR meta.profile assertions identify Document Template/Profile. XD formatCode and DocumentReference.content.format identify an established format convention where defined; MIME type identifies serialization. SubmissionSet.contentTypeCode classifies the structured payload, not a document category. SubmissionSet.purpose and Task.code identify the requested Shared Activity.

For non-document information objects such as a Task or Provenance Bundle, use information-object type and classification rather than calling them clinical Document Types. Chapter 3 retains the binding and conformance requirements; Appendix C explains XD classification and Appendix D supplies packaging mappings.

Document Lifecycle Reference

Appendix E, Understanding Document Lifecycle and Status, supplies the document-status crosswalk and the applicable CDA, FHIR, and XD metadata mappings. Do not infer a document’s finality from successful transport or structured payload acceptance.