Generated Narrative: StructureDefinition mii-pr-dokument-dokument Name Flags Card. Type Description & Constraints DocumentReference 0..* DocumentReference A reference to a document #xD; meta S 0..1 Meta Metadata about the resource #xD; profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to #xD; Slices for extension 0..* Extension Extension Slice: Unordered, Open by value:url #xD; extension:nlp-processing-status S 0..1 CodeableConcept NLP Processing Status URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status #xD; masterIdentifier S 0..1 Identifier Versionsspezifische OID des Dokuments #xD; identifier S 0..* Identifier Weitere Dokumente assoziierte Identifikatoren #xD; status S 1..1 code Zustand des Dokumentenmetadatensatzes #xD; docStatus S 0..1 code Bearbeitungsstatus des Dokumentes #xD; type S<a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( mii-iv-dokument-dokument-type )">C 0..1 CodeableConcept Charakterisierung der Dokumentart im Detail Constraints: mii-iv-dokument-dokument-type #xD; Slices for coding 1..* Coding Code defined by a terminology system Slice: Unordered, Open by value:system #xD; coding:All Slices Content/Rules for all slices #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; coding:KDL S 0..1 Coding Code defined by a terminology system Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl #xD; coding:LNC S 0..1 Coding Code defined by a terminology system Binding: DocumentTypeValueSet (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; coding:SCT S 0..1 Coding Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Typ (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; coding:XDS S 0..1 Coding Code defined by a terminology system Binding: IHE XDS typeCode (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode #xD; category S<a style="padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;; padding-left: 3px; padding-right: 3px; border: 1px maroon solid; font-weight: bold; color: #301212; background-color: #fdf4f4;" href="http://hl7.org/fhir/R4/conformance-rules.html#constraints" title="This element has or is affected by constraints ( mii-iv-dokument-dokument-category )">C 0..* CodeableConcept Charakterisierung der Dokumentenart in Übersicht Constraints: mii-iv-dokument-dokument-category #xD; Slices for coding 1..* Coding Code defined by a terminology system Slice: Unordered, Open by value:system #xD; coding:All Slices Content/Rules for all slices #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; coding:LNC S 0..1 Coding Code defined by a terminology system Binding: DocumentClassValueSet (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://loinc.org #xD; coding:SCT S 0..1 Coding Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Kategorie (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://snomed.info/sct #xD; coding:XDS S 0..1 Coding Code defined by a terminology system Binding: IHE XDS classCode (required) #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode #xD; subject S 0..1 Reference(Patient | MII PR Person Patient | MII PR Person Patient (Pseudonymisiert)) Referenz auf den Patient des Dokumentes #xD; relatesTo S 0..* BackboneElement Beziehung des Dokuments #xD; code S 1..1 code Beziehung zu anderem Dokument #xD; target S 1..1 Reference(DocumentReference) Referenz auf DocumentReference #xD; description S 0..1 string Beschreibung des Inhalts des Dokumentes #xD; securityLabel S 0..* CodeableConcept Status über den Sicherheitsbedarf des Dokuments #xD; Slices for content S 1..* BackboneElement Inhalt des Dokuments Slice: Unordered, Open by exists:attachment.url #xD; content:All Slices Content/Rules for all slices #xD; attachment S 1..1 Attachment Zugang zum Dokument #xD; contentType S 0..1 code MIME-Typ des Dokumenteninhalts #xD; language S 0..1 code Verwendete Sprache in dem Dokument #xD; data 0..1 base64Binary Dokument als Binärdaten #xD; url 0..1 url Verweis auf den lokalen Ablageort des Dokumentes #xD; creation S 0..1 dateTime Datum der Erstellung des Dokumentes #xD; format S 0..1 Coding Komplexe Formatangabe Binding: MII VS Dokument Format Code (preferred) #xD; content:Binaerdaten S 0..* BackboneElement Document referenced #xD; attachment S 1..1 Attachment Zugang zum Dokument #xD; contentType S 0..1 code MIME-Typ des Dokumenteninhalts #xD; language S 0..1 code Verwendete Sprache in dem Dokument #xD; data 1..1 base64Binary Dokument als Binärdaten #xD; url 0..0 Verweis auf den lokalen Ablageort des Dokumentes #xD; creation S 0..1 dateTime Datum der Erstellung des Dokumentes #xD; format S 0..1 Coding Komplexe Formatangabe #xD; content:Verweis S 0..* BackboneElement Document referenced #xD; attachment S 1..1 Attachment Zugang zum Dokument #xD; contentType S 0..1 code MIME-Typ des Dokumenteninhalts #xD; language S 0..1 code Verwendete Sprache in dem Dokument #xD; data 0..0 Dokument als Binärdaten #xD; url 1..1 url Verweis auf den lokalen Ablageort des Dokumentes #xD; creation S 0..1 dateTime Datum der Erstellung des Dokumentes #xD; format S 0..1 Coding Komplexe Formatangabe #xD; context S 0..1 BackboneElement Erzeugungskontext des Dokumentes #xD; encounter S 0..* Reference(Encounter | MII PR Fall Kontakt mit einer Gesundheitseinrichtung) Referenz zum FALL #xD; event S 0..* CodeableConcept Handlungen oder Prozeduren Binding: IHE XDS eventCodeList (required) #xD; coding 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; period S 0..1 Period Durchführungszeitraum #xD; facilityType S 0..1 CodeableConcept Art der Einrichtung Binding: MII VS Dokument Einrichtungart (required) #xD; coding 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; practiceSetting S 0..1 CodeableConcept Klinisches Fachgebiet Binding: MII VS Dokument Fachgebiet (required) #xD; coding 1..* Coding Code defined by a terminology system #xD; system S 1..1 uri Identity of the terminology system #xD; code S 1..1 code Symbol in syntax defined by the system #xD; Documentation for this format
Klinisches Dokument mit zugehörigen Metadaten
A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.
Usually, this is used for documents other than those defined by FHIR.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource
contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN"]
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
The only time that a resource does not have an id is when it is being submitted to the server using a create operation.
The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.
There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.
When the resource last changed - e.g. when the version changed.
This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a [read](http://hl7.org/fhir/R4/http.html#read) interaction.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.
Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The base language in which the resource is written.
Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).
Text summary of the resource, for human interpretation
A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.
Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.
This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
Status der NLP-Verarbeitung des referenzierten Dokuments
exists(f:extension)!=exists(f:*[starts-with(local-name(.), 'value')])
May be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Specific Identifier for this version of the document
Versionsspezifische OID des Dokuments. Die Angabe ist dringend empfohlen [SHALL].
Specific Identifier for this version of the document [SHALL].
The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).
Weitere Dokumente assoziierte Identifikatoren
Weitere Dokumente assoziierte Identifikatoren. Die Angabe ist optional [MAY].
Further document associated Identifiers [MAY].
Status about the condition of the document reference
Zustand des Dokumentenmetadatensatzes. Die Angabe ist dringend empfohlen [SHALL].
Status about the condition of the document reference [SHALL].
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
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("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
Status about the referenced document itself
Bearbeitungsstatus des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].
Status about the referenced document itself [SHALL].
Charakterisierung der Dokumentart im Detail
Precise description of the document type
Charakterisierung der Dokumentart im Detail. Die Angabe ist dringend empfohlen [SHALL].
Precise description of the document type [SHALL].
Empfohlen: KDL und aus KDL abgeleiteter XDS-Type-Code
Recommended: KDL and from KDL derived XDS-Type-Code
Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein
coding.where(system = 'http://dvmd.de/fhir/CodeSystem/kdl').exists() or coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDStypeCode').exists()
ClinicalDocument/code/@code The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.
A reference to a code defined by a terminology system.
Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
The identification of the code system that defines the meaning of the symbol in the code.
The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.
Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).
Need to refer to a particular code in the system.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A representation of the meaning of the code in the system, following the rules of the system.
Need to be able to carry a human-readable meaning of the code for readers that do not know the system.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
Plain text representation of the concept
A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.
Very often the text is the same as a displayName of one of the codings.
The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
Charakterisierung der Dokumentenart in Übersicht
General description of the document type
Charakterisierung der Dokumentenart in Übersicht. Die Angabe ist dringend empfohlen [SHALL].
General description of the document type [SHALL].
Empfohlen: Aus KDL abgeleiteter XDS-Category-Code
Recommended: From KDL derived XDS-Category-Code
Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein
coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDSclassCode').exists()
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
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). Must be consistent with /ClinicalDocument/code/@code
Slice für Kategorie des verwiesenen Dokuments
Referenz auf den Patient des Dokumentes. Die Angabe ist verpflichtend [MUST].
Patient reference to the document [MUST].
PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
When this document reference was created
When the document reference was created.
Referencing/indexing time is used for tracking, organizing versions and searching.
Identifies who is responsible for adding the information to the document.
Not necessarily who did the actual data entry (i.e. typist) or who was the source (informant).
TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
Which person or organization authenticates that this document is valid.
Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.
Organization which maintains the document
Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.
Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Beziehungen des verwiesenen Dokuments zu anderen Dokumenten.
This element is labeled as a modifier because documents that append to other documents are incomplete on their own.
Extensions that cannot be ignored even if unrecognized
May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).
Modifier extensions are expected to modify the meaning or interpretation of the element that contains them
Beziehung zu anderem Dokument. Die Angabe ist optional [MAY].
Typisch: `appends`, z.B. ergänzende Annotation, oder `transforms`, z.B. Formatwandlung. CAVE: `transforms` meint Dokument wurde transformiert
Typically: `appends`, e.g. additional annotation, or `transforms`, e.g. format conversion. CAVE: `transforms` means the document was transformed
The type of relationship between documents.
Referenz auf DocumentReference. Die Angabe ist verpflichtend [MUST], wenn Beziehungstyp angegeben.
Target of document relations [MUST], when relationship type is present.
.target[classCode="DOC", moodCode="EVN"].id
Beschreibung des Inhalts des Dokumentes. Die Angabe ist optional [MAY].
Description of the documents content [MAY].
What the document is about, a terse summary of the document.
Helps humans to assess whether the document is of interest.
Status über den Sicherheitsbedarf des Dokuments
Status über den Sicherheitsbedarf des Dokuments. Die Angabe wird dringend empfohlen [SHALL].
Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.
Composition.confidentiality, Composition.meta.security
Slice für ein Dokument, dessen Lokalisation verlinkt ist
Dokument, als Base64-kodierte Daten, oder Verweis, als URL, mit relevanten Metadaten zum Anhang.
Embedded Base64 encoded document content or URL reference to document.
Composition.language, Composition.title, Composition.date
DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
MIME-Typ des Dokumenteninhalts. Die Angabe ist dringend empfohlen [SHALL].
MIME type of the document content [SHALL].
Processors of the data need to be able to know how to interpret the data.
The mime type of an attachment. Any valid mime type is allowed.
ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
Verwendete Sprache in dem Dokument. Die Angabe ist dringend empfohlen [SHALL].
Empfohlen: 5-stellige Angabe. Typisch: `de-DE`
Recommended: 5-digit entry Typically: `de-DE`
Users need to be able to choose between the languages in a set of attachments.
Dokument als Binärdaten [Base64]. Die Angabe ist verpflichtend [MUST] für Textausleitungen extern und falls URL nicht angegeben wurde; ansonsten optional [MAY].
Document as binary data [Base64] [MUST] for external transfer and when URL not present; otherwise optional [MAY].
The data needs to able to be transmitted inline.
Verweis auf den lokalen Ablageort des Dokumentes
Link to the local location where the document is kept
Verweis auf den lokalen Ablageort des Dokumentes. Die Angabe ist verpflichtend [MUST], wenn `data` nicht angegeben wurde; ansonsten optional [MAY].
Link to the local location where the document is kept [MUST], when `data` not present; otherwise optional [MAY].
The data needs to be transmitted by reference.
RP.1+RP.2 - if they refer to a URL (see v2.6)
Number of bytes of content (if url provided)
The number of bytes of data that make up this attachment (before base64 encoding, if that is done).
The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.
Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.
The calculated hash of the data using SHA-1. Represented using base64.
The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R4/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.
Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).
A label or set of text to display in place of the data.
Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.
Datum der Erstellung des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].
Date of the creation of the document [SHALL].
Bezogen auf letzte Änderung gemäß MII_EX_Dokument_NLP_Processing_Status
Related to the last change regarding MII_EX_Dokument_NLP_Processing_Status
This is often tracked as an integrity issue for use of the attachment.
Formatangabe, die über den MIME-Typ hinausgehen
More complex format specification than the MIME type
Beinhaltet ValueSets von IHE Deutschland und International
Contains ValueSets of IHE Germany and International
derived from the IHE Profile or Implementation Guide templateID
The document and format referenced. There may be multiple content element repetitions, each with a different format.
Klinischer Kontext, in welchem das Dokument erzeugt wurde
Clinical context in which the document was created
These values are primarily added to help with searching for interesting/relevant documents.
Referenz zur semantisch geeignetsten Ebene des Moduls FALL. Die Angabe ist dringend empfohlen [SHALL].
Reference to the semantically most suitable level of the module FALL [SHALL].
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
Handlungen oder Prozeduren, die im Kontext dokumentiert wurden. Die Angabe ist optional [MAY].
Acts or procedures that were documented in context [MAY].
An event can further specialize the act inherent in the type, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more event codes are included, they shall not conflict with the values inherent in the class or type elements as such a conflict would create an ambiguous situation.
Zeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde. Die Angabe ist optional [MAY].
Period during which the act or procedure described in the document was performed [MAY].
DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value
Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte. Die Angabe ist optional [MAY].
Type of facility where the act or procedure was performed on the patient [MAY].
usually from a mapping to a local ValueSet
usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde. Die Angabe ist optional [MAY].
Clinical specialty in which document content was created [MAY].
CAVE: Diese Angabe entspricht nicht dem `serviceType` im Modul FALL
CAVE: This specification does not correspond to the `serviceType` in the FALL module
This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.
The Patient Information as known when the document was published. May be a reference to a version specific, or contained.
DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
Related identifiers or resources associated with the DocumentReference.
May be identifiers or resources that caused the DocumentReference or referenced Document to be created.
./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]