Implementierungsleitfaden ISiK-Dokumentenaustausch

Element id

DocumentReference.id

Short description

serverseitige, interne ID des Datensatzes

Definition

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

Comments

bedingtes Pflichtfeld/bedingtes MS: Alle von einem Server bereitgestellten Ressourcen MÜSSEN über eine id verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine idverfügen.

Data type

category

S Σ

0..1

Element id

DocumentReference.category

Short description

Dokumentklasse/-Kategorie

Alternate names

claxs

Definition

A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.

Comments

Die Kategorisierung von Dokumenten erfolgt mittels der von IHE Deutschland publizierten XDS-Class-Codes. Die übermittlung des XDS-Class-Codes ist im Rahmen der Dokumentenbereitstellung für Clients nicht verpflichtend, muss jedoch vom Server bei der Entgegennahme ggf. ergänzt und bei der Dokumentenabfrage zurückgegeben werden. Der XDS-Class-Code kann mit Hilfe der bereitgestellten ConceptMap aus dem KDL-Code ermittelt werden.

Data type

DocumentClassValueSet (example)

Binding

High-level kind of a clinical document at a macro level.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

w5: FiveWs.class
fhircomposition: Composition.class
rim: .outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
xds: DocumentEntry.class
cda: 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

0..1

There are no (further) constraints on this element

Element id

DocumentReference.category.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.category.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

1..*

Element id

DocumentReference.category.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Slicing

Unordered, Open, by $this(Pattern)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding

XDS

S Σ

1..1

CodingBindingPattern

Element id

DocumentReference.category.coding:XDS

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Binding

IHEXDSclassCode (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

{
  "system": "http://ihe-d.de/CodeSystems/IHEXDSclassCode"
}

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
CompositionDocumentReferenceMapping: Composition.category.coding[XDS]

0..1

There are no (further) constraints on this element

Element id

DocumentReference.category.coding:XDS.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.category.coding:XDS.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

S Σ

1..1

uriPattern

Element id

DocumentReference.category.coding:XDS.system

Short description

Kodiersystem

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Pattern

http://ihe-d.de/CodeSystems/IHEXDSclassCode

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

DocumentReference.category.coding:XDS.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

S Σ

1..1

Element id

DocumentReference.category.coding:XDS.code

Short description

Code

Definition

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).

Requirements

Need to refer to a particular code in the system.

Comments

Der XDS-Class-Code

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

S Σ

1..1

Element id

DocumentReference.category.coding:XDS.display

Short description

Anzeigetext

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Comments

Der Anzeigetext zum XDS-Class-Code

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

userSelected

0..1

There are no (further) constraints on this element

Element id

DocumentReference.category.coding:XDS.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

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.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: Sometimes implied by being first
rim: CD.codingRationale
orim: 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 ]

text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.category.text

Short description

Plain text representation of the concept

Definition

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.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

subject

S Σ

1..1

Reference(Patient | Practitioner | Group | Device)

Element id

DocumentReference.subject

Short description

Patientenbezug

Definition

Who or what the document is about. The document can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of farm animals, or a set of patients that share a common exposure).

Data type

Reference(Patient | Practitioner | Group | Device)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.subject
w5: FiveWs.subject[x]
fhircomposition: Composition.subject
v2: PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
rim: .participation[typeCode="SBJ"].role[typeCode="PAT"]
xds: DocumentEntry.patientId
cda: ClinicalDocument/recordTarget/
w5: FiveWs.subject
CompositionDocumentReferenceMapping: Lookup Composition.subject.resolve().identifier[PID]

0..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.subject.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

0..1

Element id

DocumentReference.subject.reference

Short description

Patienten-Link

Definition

A reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources.

Comments

Bedingtes Pflichtfeld: Clients und Server sind verpflichtet, Dokumente stets mit einem Bezug zu einem Patienten zu versehen.
Leer bleiben darf dieses Element einzig im Kontext der Dokumentenbereitstellung in Verbindung mit der Patientenzuordnung über logische Referenzen, siehe {{pagelink:Dokumentenbereitstellung text:Interaktion:Dokumentenbereitstellung > Herstellung von Patienten- und Encounterkontext > Option 5}}

Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKPatient sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

DocumentReference.subject.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources).

Comments

This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified.

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

ResourceType (extensible)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

S Σ

0..1

Element id

DocumentReference.subject.identifier

Short description

Patienten-Link (logische Referenz)

Definition

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

Comments

Bedingtes Must Support: Logische Referenzen KÖNNEN als Alternative zur Verlinkung über referencegenutzt werden. BITTE HINWEISE BEACHTEN: {{pagelink:Dokumentenbereitstellung text:Interaktion:Dokumentenbereitstellung > Herstellung von Patienten- und Encounterkontext > Option 5}}

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

0..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

use

Σ ?!

0..1

codeBinding

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.use

Short description

usual | official | temp | secondary | old (If known)

Definition

The purpose of this identifier.

Requirements

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

Comments

Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

Data type

Binding

Identifies the purpose for this identifier, if known .

IdentifierUse (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: N/A
rim: Role.code or implied by context

type

0..1

CodeableConceptBinding

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.type

Short description

Description of identifier

Definition

A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.

Requirements

Allows users to make use of identifiers when the identifier system is not known.

Comments

Data type

Identifier Type Codes (extensible)

Binding

A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.5
rim: Role.code or implied by context

system

S Σ

1..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.system

Short description

The namespace for the identifier value

Definition

Establishes the namespace for the value - that is, a URL that describes a set values that are unique.

Requirements

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

Comments

Identifier.system is always case sensitive.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/identifiers/patient

Mappings

v2: CX.4 / EI-2-4
rim: II.root or Role.id.root
servd: ./IdentifierType

value

S Σ

1..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.value

Short description

The value that is unique

Definition

The portion of the identifier typically relevant to the user and which is unique within the context of the system.

Comments

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Mappings

v2: CX.1 / EI.1
rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
servd: ./Value

period

0..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.period

Short description

Time period when id is/was valid for use

Definition

Time period during which identifier is/was valid for use.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.7 + CX.8
rim: Role.effectiveTime or implied by context
servd: ./StartDate and ./EndDate

assigner

0..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.identifier.assigner

Short description

Organization that issued id (may be just text)

Definition

Organization that issued/manages the identifier.

Comments

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: CX.4 / (CX.4,CX.9,CX.10)
rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
servd: ./IdentifierIssuingAuthority

display

0..1

There are no (further) constraints on this element

Element id

DocumentReference.subject.display

Short description

Text alternative for the resource

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

date

0..1

instant

Element id

DocumentReference.date

Short description

When this document reference was created

Alternate names

indexed

Definition

When the document reference was created.

Comments

Abweichend zu MHD V4.0.1 ist die Verwendung von date im ISiK-Kontext nicht verpflichtend. Die Motivation für die verbindliche Verwendung von date seitens IHE ist nicht nachvollziehbar. Ein entsprechender Change Request zur Harmonisierung wurde eingereicht. Das Dokumentendatum wird in attachment.creation gesetzt.

Update für Stufe 3: In MHD 4.2.0 wurde die Verpflichtung zur Angabe von date gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.

Data type

instant

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.occurrence[x]
w5: FiveWs.recorded
fhircomposition: Composition.date
rim: .availabilityTime[type="TS"]

author

S Σ

0..*

Element id

DocumentReference.author

Short description

Autor des Dokumentes

Definition

Identifies who is responsible for adding the information to the document.

Comments

In dieser Ausbaustufe ist die Nennung des Namens oder Kürzels des Autors ausreichend. Eine darüber hinaus gehende Verlinkung auf einen Practitioner (auflösbar auf dem Server) ist möglich aber nicht erforderlich.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer.actor
fhircomposition: Composition.author
v2: TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
rim: .participation[typeCode="AUT"].role[classCode="ASSIGNED"]
xds: DocumentEntry.author
cda: ClinicalDocument/author
CompositionDocumentReferenceMapping: Composition.author

0..1

There are no (further) constraints on this element

Element id

DocumentReference.author.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.author.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

Σ C

0..1

There are no (further) constraints on this element

Element id

DocumentReference.author.reference

Short description

Literal reference, Relative, internal or absolute URL

Definition

Comments

Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

DocumentReference.author.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

ResourceType (extensible)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

DocumentReference.author.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

S Σ

0..1

There are no (further) constraints on this element

Element id

DocumentReference.author.display

Short description

Text alternative for the resource

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

authenticator

0..1

Reference(Practitioner | PractitionerRole | Organization)

There are no (further) constraints on this element

Element id

DocumentReference.authenticator

Short description

Who/what authenticated the document

Definition

Which person or organization authenticates that this document is valid.

Comments

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.

Data type

Reference(Practitioner | PractitionerRole | Organization)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer.actor
w5: FiveWs.witness
fhircomposition: Composition.attester
v2: TXA-10
rim: .participation[typeCode="AUTHEN"].role[classCode="ASSIGNED"]
xds: DocumentEntry.legalAuthenticator
cda: ClinicalDocument/legalAuthenticator

custodian

0..1

There are no (further) constraints on this element

Element id

DocumentReference.custodian

Short description

Organization which maintains the document

Definition

Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.

Comments

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.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.performer.actor
fhircomposition: Composition.custodian
rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]

relatesTo

S Σ

0..*

Element id

DocumentReference.relatesTo

Short description

Relationships to other documents

Definition

Relationships that this document has with other document references that already exist.

Comments

Inbesondere relevant im Kontext von Updates. Bei inhaltlichen Updates MUSS eine replaces-Relation angegeben werden.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.relatesTo
rim: .outboundRelationship
xds: DocumentEntry Associations

0..1

There are no (further) constraints on this element

Element id

DocumentReference.relatesTo.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.relatesTo.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.relatesTo.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

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).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

code

1..1

codeBinding

Element id

DocumentReference.relatesTo.code

Short description

replaces | transforms | signs | appends

Definition

The type of relationship that this document has with anther document.

Comments

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

Data type

DocumentRelationshipType (required)

Binding

The type of relationship between documents.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.relatesTo.code
rim: .outboundRelationship.typeCode
xds: DocumentEntry Associations type
CompositionDocumentReferenceMapping: Composition.relatesTo.code

target

1..1

Reference(DocumentReference)

Element id

DocumentReference.relatesTo.target

Short description

Target of the relationship

Definition

The target document of this relationship.

Data type

Reference(DocumentReference)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.relatesTo.target
rim: .target[classCode="DOC", moodCode="EVN"].id
xds: DocumentEntry Associations reference
CompositionDocumentReferenceMapping: Lookup Composition.relatesTo.targetReference.resolve().identifier

description

0..1

Element id

DocumentReference.description

Short description

Human-readable description

Definition

Human-readable description of the source document.

Requirements

Helps humans to assess whether the document is of interest.

Comments

Optionaler Freitext zur ergänzenden Beschreibung des Dokumentes. Die eigentliche menschenlesbare Bezeichnung des Dokuments zur Anzeige in Benutzeroberflächen sollte in 'content.attachment.title' angegeben werden.

Update für Stufe 5: Ab dieser Stufe ist für die menschenlesbare Bezeichnung des Dokuments das Element content.attachment.title zu verwenden. Die bisherige Nutzung von DocumentReference.description entfällt zugunsten einer besseren Angleichung an MHD und die ePA-Spezifikation. Implementierungen sollten daher den Titel des Dokuments ausschließlich in content.attachment.title angeben.

Das Element 'description' kann weiterhin verwendet werden, um inhaltliche Hinweise zum Dokument, eine knappe Zusammenfassung oder ergänzende Kommentare bereitzustellen.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: TXA-25
rim: .outboundRelationship[typeCode="SUBJ"].target.text
xds: DocumentEntry.comments

securityLabel

S Σ

1..*

CodeableConceptBinding

Element id

DocumentReference.securityLabel

Short description

Vertraulichkeit

Definition

A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.

Requirements

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

Comments

Die Bereitstellung der Vertraulichkeitsinformation durch den Ersteller des Dokumentes ist verpflichtend. Ebenso sind Dokumentenserver verpflichtet, diese Information zu persistieren und bei der Dokumentenabfrage zu reproduzieren. Die ISiK-Spezifikation trifft jedoch keine Annahmen darüber, wie sich einzelne Vertraulichkeitsstufen auf die Zugriffsberechtigungen verschiedener benutzer auf ein Dokument auswirken. Im ISiK-Kontext ist die Angabe einer der drei Vertraulichkeitsstufen N | R | V verpflichtend, jedoch ohne Einschränkung der Verwendung zusätzlicher Vertraulichkeits-Flags.

[Konsens der Arbeitsgruppe vom 12.11.2021]

Data type

ISiKConfidentialityCodes (required)

Binding

Security Labels from the Healthcare Privacy and Security Classification System.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.confidentiality, Composition.meta.security
v2: TXA-18
rim: .confidentialityCode
xds: DocumentEntry.confidentialityCode
cda: ClinicalDocument/confidentialityCode/@code

content

S Σ

1..1

Element id

DocumentReference.content

Short description

Beschreibung des Dokumenteninhaltes

Definition

The document and format referenced. There may be multiple content element repetitions, each with a different format.

Comments

Die Kardinalität wurde angepasst, um den Vorgaben von IHE MHD zu ensprechen [Änderung im Zuge der Kommentierung Stufe 3].

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Bundle(Composition+*)
rim: document.text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

attachment

S Σ

1..1

Attachment

Element id

DocumentReference.content.attachment

Short description

Anhang

Definition

The document or URL of the document along with critical metadata to prove content has integrity.

Data type

Attachment

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.language, Composition.title, Composition.date
v2: TXA-3 for mime type
rim: document.text
xds: DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
cda: ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

contentType

S Σ

1..1

codeBinding

Element id

DocumentReference.content.attachment.contentType

Short description

Mimetype des Dokumentes

Definition

Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.

Requirements

Processors of the data need to be able to know how to interpret the data.

Comments

Mimetype (Dateityp) des Dokumentes (z.B. "application/pdf")

Data type

Binding

The mime type of an attachment. Any valid mime type is allowed.

Mime Types (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

text/plain; charset=UTF-8, image/png

Mappings

v2: ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
rim: ./mediaType, ./charset
CompositionDocumentReferenceMapping: `application/html` für den extrahierten Narrative, `application/fhir+xml` oder `application/fhir+json` für das Bundle

language

S Σ

1..1

codeBinding

Element id

DocumentReference.content.attachment.language

Short description

Sprache, in der das Dokument verfasst wurde.

Definition

The human language of the content. The value can be any valid value according to BCP 47.

Requirements

Users need to be able to choose between the languages in a set of attachments.

Comments

Kann bei Systemen, die keine Mehrsprachigkeit unterstützen, fest auf "de" oder "de-DE" gesetzt werden.

Data type

Binding

A human language.

CommonLanguages (preferred)

Binding extensions

maxValueSet	AllLanguages

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

en-AU

Mappings

rim: ./language
CompositionDocumentReferenceMapping: =de sofern keine abweichende Angabe in Composition.language

data

0..1

Element id

DocumentReference.content.attachment.data

Short description

Base64-codierte Binärdaten

Definition

The actual data of the attachment - a sequence of bytes, base64 encoded.

Requirements

The data needs to able to be transmitted inline.

Comments

Um die Suche nach Dokumenten effizient zu gestalten, dürfen die Dokumente selbst nicht in die DocumentReference eingebettet werden, sondern müssen als separates Datenobjekt referenziert werden.

Update für Stufe 3: Die Ausnahme bildet die Interaktion "Dokumentenbereitstellung", bei der die Binärdaten des Dokumentes eingebettet in die DocumentReference an den Server übermittelt und dort dann in eine separate Ressource ausgelagert und über Attachment.url referenziert werden.

Es ist zu beachten, dass diese base64-codierten Daten wiederum ein FHIR-Bundle (z.B. ein MIO oder ein ISiK Bericht aus einem Subsystem) repräsentieren können. Um eine einheitliche Handhabung der Dokumente für Clients zu ermöglichen werden diese trotz strukturiertem Inhalt per base64 abgebildet.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: ED.5
rim: ./data

url

S Σ

0..1

url

Element id

DocumentReference.content.attachment.url

Short description

Referenz auf Dokument

Definition

A location where the data can be accessed.

Requirements

The data needs to be transmitted by reference.

Comments

Um die Suche nach Dokumenten effizient zu gestalten, dürfen die Dokumente selbst nicht in die DocumentReference eingebettet werden, sondern müssen als separates Datenobjekt referenziert werden.

Wird ein separates Datenobjekt im ISIK-Kontext referenziert, so MUSS dieses konform zum Profil ISIKBinary aus dem Basismodul sein.

Data type

url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

http://www.acme.com/logo-small.png

Mappings

v2: RP.1+RP.2 - if they refer to a URL (see v2.6)
rim: ./reference/literal
CompositionDocumentReferenceMapping: vom Server festgelegter Speicherort des Bundles/Narratives

size

0..1

unsignedInt

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.size

Short description

Number of bytes of content (if url provided)

Definition

The number of bytes of data that make up this attachment (before base64 encoding, if that is done).

Requirements

Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.

Comments

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.

Data type

unsignedInt

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A (needs data type R3 proposal)

hash

0..1

There are no (further) constraints on this element

Element id

DocumentReference.content.attachment.hash

Short description

Hash of the data (sha-1, base64ed)

Definition

The calculated hash of the data using SHA-1. Represented using base64.

Requirements

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).

Comments

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 for mechanism to protect a resource with a digital signature.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"]

title

S Σ

1..1

Element id

DocumentReference.content.attachment.title

Short description

Bezeichnung des Dokuments

Definition

A label or set of text to display in place of the data.

Requirements

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.

Comments

Menschenlesbare Bezeichnung des Dokuments zur Anzeige in Benutzeroberflächen, z.B. als Titel in einer Dokumentenliste ('Lungenfunktionstest vom 18.02.2022').

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Examples
General

Official Corporate Logo

Mappings

rim: ./title/data
CompositionDocumentReferenceMapping: Composition.title

creation

S Σ

1..1

dateTime

Element id

DocumentReference.content.attachment.creation

Short description

Dokumentendatum

Definition

The date that the attachment was first created.

Requirements

This is often tracked as an integrity issue for use of the attachment.

Comments

Es obliegt dem erzeugenden System, zu entscheiden, welches Datum als Dokumentendatum geeignet ist, z.B. Datum der Erstellung oder Datum der letzten Änderung

Data type

dateTime

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A (needs data type R3 proposal)
CompositionDocumentReferenceMapping: Composition.date

format

S Σ

1..1

CodingBinding

Element id

DocumentReference.content.format

Short description

Format des Dokumentes

Definition

An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.

Comments

Sofern das Dokument nicht auf einem standardisierten, strukturierten Austauschformat (z.B. CDA) basiert, für dessen Interpretation ein konkretes Schema herangezogen werden muss, genügt die Angabe des Codes "urn:ihe:iti:xds:2017:mimeTypeSufficient"

Data type

Binding

Document Format Codes.

IHEXDSformatCodeDE (required)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.meta.profile
rim: document.text
xds: DocumentEntry.formatCode
cda: derived from the IHE Profile or Implementation Guide templateID
CompositionDocumentReferenceMapping: =urn:ihe:iti:xds:2017:mimeTypeSufficient

context

S Σ

1..1

There are no (further) constraints on this element

Element id

DocumentReference.context

Short description

Clinical context of document

Definition

The clinical context in which the document was prepared.

Comments

These values are primarily added to help with searching for interesting/relevant documents.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

modifierExtension

Σ ?! C

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.modifierExtension

Short description

Extensions that cannot be ignored even if unrecognized

Alternate names

extensions, user content, modifiers

Definition

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

Requirements

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: N/A

encounter

0..1

Reference(Encounter | EpisodeOfCare)

Element id

DocumentReference.context.encounter

Short description

Aufenthaltsbezug

Definition

Describes the clinical encounter or type of care that the document content is associated with.

Comments

Hinweis Kompatibilität: In MHD 4.2.0 wurde das Verbot der Angabe einer Encounter-Referenz gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.

Data type

Reference(Encounter | EpisodeOfCare)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

workflow: Event.context
w5: FiveWs.context
fhircomposition: Composition.encounter
rim: unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
CompositionDocumentReferenceMapping: Lookup Composition.encounter.resolve().identifier

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

reference

S Σ C

1..1

Element id

DocumentReference.context.encounter.reference

Short description

Encounter-Link

Definition

Comments

Begründung Pflichtfeld: Die Verlinkung auf eine Encounter-Ressource dient der technischen Zuordnung der Dokumentation zu einem Aufenthalt und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKKontaktGesundheitseinrichtung sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.

Data type

Conditions

The cardinality or value of this element may be affected by these constraints: ref-1

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

type

0..1

uriBinding

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter.type

Short description

Type the reference refers to (e.g. "Patient")

Definition

The expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent.

Comments

Data type

Binding

Aa resource (or, for logical models, the URI of the logical model).

ResourceType (extensible)

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

identifier

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter.identifier

Short description

Logical reference, when literal reference is not known

Definition

Comments

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: .identifier

display

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.encounter.display

Short description

Text alternative for the resource

Definition

Plain text narrative that identifies the resource in addition to the resource reference.

Comments

This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

rim: N/A

event

0..*

CodeableConceptBinding

Element id

DocumentReference.context.event

Short description

Main clinical acts documented

Definition

This list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.

Comments

Binding auf IHE-DE Terminologie hinzugefügt

Data type

IHEXDSeventCodeList (required)

Binding

This list of codes represents the main clinical acts being documented.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.event.code
rim: .code
xds: DocumentEntry.eventCodeList

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.event.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

coding

1..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding

Short description

Code defined by a terminology system

Definition

A reference to a code defined by a terminology system.

Requirements

Allows for alternative encodings within a code system, and translations to other code systems.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1-8, C*E.10-22
rim: union(., ./translation)
orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.id

Short description

Unique id for inter-element referencing

Definition

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

Data type

Mappings

rim: n/a

extension

0..*

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.extension

Short description

Additional content defined by implementations

Alternate names

extensions, user content

Definition

Comments

Data type

Slicing

Unordered, Open, by url(Value)

Extensions are always sliced by (at least) url

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
ext-1: Must have either extensions or value[x], not both
extension.exists() != value.exists()

Mappings

rim: n/a

system

1..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.system

Short description

Identity of the terminology system

Definition

The identification of the code system that defines the meaning of the symbol in the code.

Requirements

Need to be unambiguous about the source of the definition of the symbol.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.3
rim: ./codeSystem
orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem

version

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.version

Short description

Version of the system - if relevant

Definition

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.7
rim: ./codeSystemVersion
orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion

code

1..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.code

Short description

Symbol in syntax defined by the system

Definition

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).

Requirements

Need to refer to a particular code in the system.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.1
rim: ./code
orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code

display

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.display

Short description

Representation defined by the system

Definition

A representation of the meaning of the code in the system, following the rules of the system.

Requirements

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.2 - but note this is not well followed
rim: CV.displayName
orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName

userSelected

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.coding.userSelected

Short description

If this coding was chosen directly by the user

Definition

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Requirements

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.

Comments

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: Sometimes implied by being first
rim: CD.codingRationale
orim: 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 ]

text

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.event.text

Short description

Plain text representation of the concept

Definition

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.

Requirements

Comments

Very often the text is the same as a displayName of one of the codings.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

v2: C*E.9. But note many systems use C*E.2 for this
rim: ./originalText[mediaType/code="text/plain"]/data
orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText

period

0..1

There are no (further) constraints on this element

Element id

DocumentReference.context.period

Short description

Time of service that is being documented

Definition

The time period over which the service that is described by the document was provided.

Data type

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: Composition.event.period
rim: .effectiveTime
xds: DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
cda: ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value

facilityType

1..1

CodeableConceptBinding

Element id

DocumentReference.context.facilityType

Short description

Art der Einrichtung, aus der das Dokument stammt

Definition

The kind of facility where the patient was seen.

Comments

Kann, sofern keine abweichende Information bekannt ist auf "KHS" gesetzt werden.

Data type

IHEXDShealthcareFacilityTypeCode (required)

Binding

XDS Facility Type.

Constraints

ele-1: All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())

Mappings

fhircomposition: usually from a mapping to a local ValueSet
rim: .participation[typeCode="LOC"].role[classCode="DSDLOC"].code
xds: DocumentEntry.healthcareFacilityTypeCode
cda: usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
CompositionDocumentReferenceMapping: =KHS, sofern nichts anderes bekannt

practiceSetting

1..1

CodeableConceptBinding

Element id

DocumentReference.context.practiceSetting

Short description

Additional details about where the content was created (e.g. clinical specialty)

Definition

This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.

Requirements

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

Comments

Binding auf IHE-DE Terminologie hinzugefügt

Data type