Implementierungsleitfaden ISiK-Dokumentenaustausch

Dokumentenmetadaten (DocumentReference)

Die nachfolgenden Festlegungen spezifizieren die Minimalanforderungen für die Bereitstellung von Dokumentenmetadaten im Rahmen des Bestätigungsverfahrens der gematik.

Motivation

Die Ressource DocumentReference enthält die Metadaten, die für die Verwaltung von und die Suche nach Dokumenten benötigt werden. Der Inhalt des Dokumentes wird über DocumentReference.content beschrieben und über DocumentReference.content.attachment referenziert. Die Trennung von Dokument und Metadaten ermöglicht Clients die effiziente Suche und Auflistung von verfügbaren Dokumenten, ohne dass diese vollständig vom Server geladen werden müssen. Servern ermöglicht dieser Ansatz die Trennung zwischen den Metadaten in einer Datenbank und der Dokumentenablage in z.B. einem Dateisystem.

Kompatibilität

Dieses Profil basiert auf dem Profil "MHD DocumentReference Comprehensive UnContained References Option" (Version 4.2.0) von IHE International.

Abweichungen vom IHE-Profil

Die Verwendung von DocumentReference.docStatus ist im ISiK-Kontext gestattet.
DocumentReference.category muss vom Client bei Vorhandensein eines KDL-Codes in DocumentReference.type nicht gefüllt werden. Bei der Verarbeitung auf dem Server im Rahmen der Interaktion "Dokumentenbereitstellung" wird DocumentReference.category anhand der KDL-Mappings ergänzt und damit die IHE-Kompatibilität hergestellt.
DocumentReference.sourcePatientInfo muss im Rahmen von ISiK nicht gefüllt werden

Einschränkungen des IHE-Profils

Elemente mit ValueSet-Bindings ohne verbindliche Vorgabe seitens IHE wurden auf die in Deutschland gebräuchlichen Terminologien (gemäß der Festlegungen von IHE Deutschland e.V.) eingeschränkt.

FHIR-Profil

DocumentReference

Canonical URL: https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten

ISiKDokumentenMetadaten (DocumentReference)	I		DocumentReference	There are no (further) constraints on this element Element id DocumentReference Short description A reference to a document Definition 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. Comments Usually, this is used for documents other than those defined by FHIR. Data type DocumentReference Constraints dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources `contained.contained.empty()` dom-4: 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()` dom-3: 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()` dom-6: A resource should have narrative for robust management text.`div`.exists() dom-5: If a resource is contained in another resource, it SHALL NOT have a security label `contained.meta.security.empty()` Mappings rim: Entity. Role, or Act workflow: Event fhircomposition: when describing a Composition rim: Document[classCode="DOC" and moodCode="EVN"] cda: when describing a CDA
id	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.id Short description Logical id of this artifact Definition The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. Comments The only time that a resource does not have an id is when it is being submitted to the server using a create operation. Data type string
meta	Σ	0..1	Meta	There are no (further) constraints on this element Element id DocumentReference.meta Short description Metadata about the resource Definition 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. Data type Meta Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
implicitRules	Σ ?!	0..1	uri	There are no (further) constraints on this element Element id DocumentReference.implicitRules Short description A set of rules under which this content was created Definition 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. Comments 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. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
language		0..1	codeBinding	There are no (further) constraints on this element Element id DocumentReference.language Short description Language of the resource content Definition The base language in which the resource is written. Comments 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). Data type code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a
text		0..1	Narrative	There are no (further) constraints on this element Element id DocumentReference.text Short description Text summary of the resource, for human interpretation Alternate names narrative, html, xhtml, display Definition 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. Comments 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. Data type Narrative Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A rim: Act.text?
contained		0..*	Resource	There are no (further) constraints on this element Element id DocumentReference.contained Short description Contained, inline Resources Alternate names inline resources, anonymous resources, contained resources Definition 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. Comments 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. Data type Resource Mappings rim: Entity. Role, or Act rim: N/A
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition May be used to represent additional information that is not part of the basic definition of the resource. 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
modifierExtension	?! I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.modifierExtension Short description Extensions that cannot be ignored Alternate names extensions, user content Definition 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). Requirements 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
masterIdentifier	S Σ	1..1	Identifier	Element id DocumentReference.masterIdentifier Short description Versionsspezifische OID des Dokumentes Definition Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document. Requirements 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.). Comments CDA Document Id extension and root. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier fhircomposition: Composition.identifier v2: TXA-12 rim: .id xds: DocumentEntry.uniqueId cda: ClinicalDocument/id CompositionDocumentReferenceMapping: Bundle.identifier
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
use	Σ ?!	0..1	codeBinding	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.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 code 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 rim: n/a v2: N/A rim: Role.code or implied by context
type	Σ	0..1	CodeableConceptBinding	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.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 This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. Data type CodeableConcept Binding A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. Identifier Type Codes (extensible) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD v2: CX.5 rim: Role.code or implied by context
system	S Σ	1..1	uriPattern	Element id DocumentReference.masterIdentifier.system Short description Namensraum des Identifiers 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 Fix: `urn:ietf:rfc:3986` Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern urn:ietf:rfc:3986 Mappings rim: n/a v2: CX.4 / EI-2-4 rim: II.root or Role.id.root servd: ./IdentifierType
value	S Σ	1..1	string	Element id DocumentReference.masterIdentifier.value Short description Wert des Identifiers Definition The portion of the identifier typically relevant to the user and which is unique within the context of the system. Comments OID mit URI-Präfix "urn:oid:". Es sei darauf hingewiesen, dass OIDs auf Basis von UUIDs generiert werden können, ohne einen eigenen Namesraum zu beantragen. Zunächst müssen hierzu alle 128 Bit der UUID in einen Integer-Wert umgerechnet werden. Das Ergebnis muss ohne Bindestriche an die Root-OID '2.25' angehängt werden. Siehe IHE International - Creating Unique IDs - OID and UUID. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples General 123456 Mappings rim: n/a 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	Σ I	0..1	Period	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.period Short description Time period when id is/was valid for use Definition Time period during which identifier is/was valid for use. Comments A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` per-1: If present, start SHALL have a lower value than end `start.hasValue().not() or end.hasValue().not() or (start <= end)` Mappings rim: n/a v2: DR rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] v2: CX.7 + CX.8 rim: Role.effectiveTime or implied by context servd: ./StartDate and ./EndDate
assigner	Σ I	0..1	Reference(Organization)	There are no (further) constraints on this element Element id DocumentReference.masterIdentifier.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 Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) 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
identifier	S Σ	0..*	Identifier	Element id DocumentReference.identifier Short description Other identifiers for the document Definition Other identifiers associated with the document, including version independent identifiers. Comments Abweichend zu MHD V4.0.1 ist die Angabe eines Identifiers in ISiK nicht erforderlich. Ein solcher kann bei Bedarf (z.B. zur Weitergabe des Dokumentes per XDS) erzeugt werden. [Konsens der Arbeitsgruppe vom 12.11.2021] Update für Stufe 3: In MHD 4.2.0 wurde die Verpflichtung zur Angabe eines Identifiers gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD. Data type Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier workflow: Event.identifier w5: FiveWs.identifier v2: TXA-16? rim: .id / .setId xds: DocumentEntry.entryUUID CompositionDocumentReferenceMapping: Composition.identifier
status	S Σ ?!	1..1	codeBinding	Element id DocumentReference.status Short description Status des Dokumentenmetadatensatzes Definition The status of this document reference. Comments Der Status des Dokumentes wird in DocumentReference.docStatus gesetzt! Data type code Binding The status of the document reference. DocumentReferenceStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a workflow: Event.status w5: FiveWs.status v2: TXA-19 rim: 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" xds: DocumentEntry.availabilityStatus CompositionDocumentReferenceMapping: =current
docStatus	S Σ	0..1	codeBinding	Element id DocumentReference.docStatus Short description Bearbeitungsstatus des Dokumentes Definition The status of the underlying document. Comments Abweichend zu MHD V4.0.1 ist die Verwendung von docStatus im ISiK-Kontext erlaubt. Doe Verwendung von docStatus bleibt jedoch optional, da nicht alle Dokumentenerzeugende Systeme einen expliziten Freigabe-Workflow haben. Dokumentenserver müssen jedoch in der Lage sein, den Dokumentenstatus (sofern vorhanden) zu persistieren, anzuzeigen und zu reproduzieren. [Konsens der Arbeitsgruppe vom 10.12.2021] Data type code Binding Status of the underlying document. CompositionStatus (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a w5: FiveWs.status fhircomposition: Composition.status v2: TXA-17 rim: .statusCode CompositionDocumentReferenceMapping: Composition.status
type	S Σ	1..1	CodeableConceptBinding	Element id DocumentReference.type Short description Dokumententyp Definition Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced. Comments Im ISiK-Kontext ist die Typisierung eines Dokumentes mit Hilfe eines KDL-Codes und des IHE-XDS-Type-Codes erforderlich und ein Server MUSS beide Kodierungen bereitstellen - trotz der Kardinalität DocumentReference.type.coding:XDS 0..1 -, jedoch ist der IHE-XDS-Type-Code bei Übermittlung für Clients nicht verpflichtend (s.u. zu XDS). Während KDL-Codes eine feingranulare Dokumentenklassifikation für die gezielte Suche nach medizinischen und Administrativen Dokumenten ermöglichen, sind IHE-XDS-Type-Codes für den einrichtungsübergreifenden Dokumentenaustausch maßgeblich. Der XDS-Type-Code kann mit Hilfe der bereitgestellten ConceptMaps aus dem KDL-Code ermittelt werden. Weitere Typisierungen (z.B. nach SNOMED oder LOINC) sind uneingeschränkt erlaubt. [Konsens der Arbeitgruppe vom 18.02.2022]. Im Falle, dass der Code 'UNK' entsprechend der ConceptMap verwendet werden soll, MUSS das System 'http://terminology.hl7.org/CodeSystem/v3-NullFlavor' verwendet werden. Data type CodeableConcept Binding Precise type of clinical document. DocumentTypeValueSet (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD workflow: Event.code w5: FiveWs.class fhircomposition: Composition.type v2: TXA-2 rim: ./code xds: DocumentEntry.type cda: 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.
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.type.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
coding	Σ	1..*	Coding	Element id DocumentReference.type.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 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. Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
KDL	S Σ	1..1	CodingBindingPattern	Element id DocumentReference.type.coding:KDL Short description Dokumenttyp gem. KDL-Terminologie 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 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. Data type Coding Binding (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern { "system": "http://dvmd.de/fhir/CodeSystem/kdl" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding CompositionDocumentReferenceMapping: Composition.type.coding[KDL]
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.coding:KDL.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.type.coding:KDL.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
system	S Σ	1..1	uriPattern	Element id DocumentReference.type.coding:KDL.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 Fix: "http://dvmd.de/fhir/CodeSystem/kdl" Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://dvmd.de/fhir/CodeSystem/kdl Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.coding:KDL.version Short description Version of the system - if relevant Definition 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. Comments 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	Element id DocumentReference.type.coding:KDL.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 KDL-Code Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	S Σ	1..1	string	Element id DocumentReference.type.coding:KDL.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 KDL-Code Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id DocumentReference.type.coding:KDL.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 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a 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 ]
XDS	S Σ	0..1	CodingBindingPattern	Element id DocumentReference.type.coding:XDS Short description Dokumenttyp gem. IHE-De-Terminologie 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 Die Übermittlung des XDS-Type-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-Type-Code kann über die im Rahmen der KDL-Spezifikation publizierten ConceptMaps aus dem KDL-Code ermittelt werden Data type Coding Binding IHEXDStypeCode (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/IHEXDStypeCode" } Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding CompositionDocumentReferenceMapping: Composition.type.coding[XDS]
id		0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.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 string Mappings rim: n/a
extension	I	0..*	Extension	There are no (further) constraints on this element Element id DocumentReference.type.coding:XDS.extension Short description Additional content defined by implementations Alternate names extensions, user content Definition 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
system	S Σ	1..1	uriPattern	Element id DocumentReference.type.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 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. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Pattern http://ihe-d.de/CodeSystems/IHEXDStypeCode Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.coding:XDS.version Short description Version of the system - if relevant Definition 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. Comments 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	Element id DocumentReference.type.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-Type-Code Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	S Σ	1..1	string	Element id DocumentReference.type.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-Type-Code Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	There are no (further) constraints on this element Element id DocumentReference.type.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 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a 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	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.type.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 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
category	S Σ	0..1	CodeableConcept	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 CodeableConcept Binding High-level kind of a clinical document at a macro level. DocumentClassValueSet (example) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD 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
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
coding	Σ	1..*	Coding	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 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. Data type Coding Sliced: Unordered, Open, by $this(Pattern) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.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 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. Data type Coding 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 rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding CompositionDocumentReferenceMapping: Composition.category.coding[XDS]
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 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 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. Data type uri 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 rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.category.coding:XDS.version Short description Version of the system - if relevant Definition 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. Comments 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	S Σ	1..1	code	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 code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	S Σ	1..1	string	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 string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	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 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a 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	Σ	0..1	string	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 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
subject	S Σ I	1..1	Reference(Patient)	Element id DocumentReference.subject Short description Patientenbezug des Dokumentes 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). Comments Im ISIK-Kontext MUSS der referenzierte Patient konform zum ISIKPatient des Basismoduls sein. Für sonstige Kontexte siehe FHIR Kernspezifikation Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) 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]
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
reference	S Σ I	1..1	string	Element id DocumentReference.subject.reference Short description Absolute oder relative URL des Patienten auf dem Server 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 Absolute oder relative URL des Patienten auf dem Server Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
type	Σ	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 uri 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 rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id DocumentReference.subject.identifier Short description Logical reference, when literal reference is not known 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 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 Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier rim: .identifier
display	Σ	0..1	string	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 string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
date	Σ	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 rim: n/a workflow: Event.occurrence[x] w5: FiveWs.recorded fhircomposition: Composition.date rim: .availabilityTime[type="TS"]
author	S Σ I	0..*	Reference(Practitioner \| PractitionerRole \| Organization \| Device \| Patient \| RelatedPerson)	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 Pracitioner (auflösbar auf dem Server) ist möglich aber nicht erforderlich. Data type Reference(Practitioner \| PractitionerRole \| Organization \| Device \| Patient \| RelatedPerson) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) 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
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
reference	Σ I	0..1	string	There are no (further) constraints on this element Element id DocumentReference.author.reference Short description Literal reference, Relative, internal or absolute URL 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 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 string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
type	Σ	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. 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 uri 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 rim: N/A
identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element id DocumentReference.author.identifier Short description Logical reference, when literal reference is not known 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 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 Identifier Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CX / EI (occasionally, more often EI maps to a resource id or a URL) rim: II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd: Identifier rim: .identifier
display	S Σ	0..1	string	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 string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: N/A
authenticator	I	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())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) 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	I	0..0	Reference(Organization)	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 Einschränkung der Kardinalität analog MHD V4.0.1 Data type Reference(Organization) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) workflow: Event.performer.actor fhircomposition: Composition.custodian rim: .participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
relatesTo	S Σ	0..*	BackboneElement	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 BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a fhircomposition: Composition.relatesTo rim: .outboundRelationship xds: DocumentEntry Associations
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	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 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. Comments 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. Data type Extension 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 rim: N/A
code	Σ	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 code Binding The type of relationship between documents. DocumentRelationshipType (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a fhircomposition: Composition.relatesTo.code rim: .outboundRelationship.typeCode xds: DocumentEntry Associations type CompositionDocumentReferenceMapping: Composition.relatesTo.code
target	Σ I	1..1	Reference(DocumentReference)	Element id DocumentReference.relatesTo.target Short description Target of the relationship Definition The target document of this relationship. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(DocumentReference) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) fhircomposition: Composition.relatesTo.target rim: .target[classCode="DOC", moodCode="EVN"].id xds: DocumentEntry Associations reference CompositionDocumentReferenceMapping: Lookup Composition.relatesTo.targetReference.resolve().identifier
description	S Σ	1..1	string	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 Genaue menschenlesbare Beschreibung des Dokumentes, z.B. "Lungenfunktionstest vom 18.02.2022" Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: TXA-25 rim: .outboundRelationship[typeCode="SUBJ"].target.text xds: DocumentEntry.comments CompositionDocumentReferenceMapping: Composition.title
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 des 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 CodeableConcept Binding Security Labels from the Healthcare Privacy and Security Classification System. ISiKConfidentialityCodes (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD fhircomposition: Composition.confidentiality, Composition.meta.security v2: TXA-18 rim: .confidentialityCode xds: DocumentEntry.confidentialityCode cda: ClinicalDocument/confidentialityCode/@code
content	S Σ	1..1	BackboneElement	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 BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a fhircomposition: Bundle(Composition+) rim:* document.text
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	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 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 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. Comments 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. Data type Extension 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 rim: N/A
attachment	S Σ I	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. Comments When providing a summary view (for example with Observation.value[x]) Attachment should be represented with a brief display text such as "Signed Procedure Consent". Data type Attachment Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` att-1: If the Attachment has data, it SHALL have a contentType `data.empty() or contentType.exists()` Mappings rim: n/a v2: ED/RP rim: ED 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
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 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 code 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 rim: n/a 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 code Binding A human language. CommonLanguages (preferred) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Examples General en-AU Mappings rim: n/a rim: ./language CompositionDocumentReferenceMapping: =de sofern keine abweichende Angabe in Composition.language
data	S	0..1	base64Binary	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 base64Binary Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a 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. 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. 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 rim: n/a 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	Σ	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 rim: N/A (needs data type R3 proposal)
hash	Σ	0..1	base64Binary	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 base64Binary Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: .integrityCheck[parent::ED/integrityCheckAlgorithm="SHA-1"]
title	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.content.attachment.title Short description Label to display in place of the data 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 Note that FHIR strings SHALL NOT exceed 1MB in size Data type string 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: n/a rim: ./title/data
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 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 Coding 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 rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding 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	BackboneElement	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 BackboneElement Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a rim: outboundRelationship[typeCode="SUBJ"].target[classCode<'ACT']
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
modifierExtension	Σ ?! I	0..*	Extension	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 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 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. Comments 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. Data type Extension 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 rim: N/A
encounter	S I	0..1	Reference(Encounter \| EpisodeOfCare)	Element id DocumentReference.context.encounter Short description Context of the document content Definition Describes the clinical encounter or type of care that the document content is associated with. Comments Abweichend zu MHD V4.0.1 ist die Verwendung der Encounter-Referenz im ISiK-Kontext erlaubt. `Wird ein Encounter im ISIK-Kontext referenziert, so MUSS dieser konform zum Profil [ISIKKontaktGesundheitseinrichtung](https://gematik.de/fhir/isik/v3/Basismodul/StructureDefinition/ISiKKontaktGesundheitseinrichtung) aus dem Basismodul sein.` Update für Stufe 3: 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())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) 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
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 CodeableConcept Binding This list of codes represents the main clinical acts being documented. IHEXDSeventCodeList (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD fhircomposition: Composition.event.code rim: .code xds: DocumentEntry.eventCodeList
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
coding	Σ	1..1	Coding	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 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. Data type Coding Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE subset one of the sets of component 1-3 or 4-6 rim: CV orim: fhir:Coding rdfs:subClassOf dt:CDCoding v2: CE.1-8, CE.10-22 rim: union(., ./translation) orim: fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
id		0..1	string	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 string Mappings rim: n/a
extension	I	0..*	Extension	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 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. Comments 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. Data type Extension Sliced: 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 rim: N/A
system	Σ	1..1	uri	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 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. Data type uri Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.3 rim:* ./codeSystem orim: fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
version	Σ	0..1	string	There are no (further) constraints on this element Element id DocumentReference.context.event.coding.version Short description Version of the system - if relevant Definition 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. Comments 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. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.7 rim:* ./codeSystemVersion orim: fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
code	Σ	1..1	code	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. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type code Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.1 rim:* ./code orim: fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
display	Σ	0..1	string	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. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.2 - but note this is not well followed rim:* CV.displayName orim: fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
userSelected	Σ	0..1	boolean	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 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. Data type boolean Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a 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	Σ	0..1	string	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 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. Comments Very often the text is the same as a displayName of one of the codings. Data type string Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE.9. But note many systems use CE.2 for this rim: ./originalText[mediaType/code="text/plain"]/data orim: fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
period	Σ I	0..1	Period	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. Comments A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. Data type Period Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` per-1: If present, start SHALL have a lower value than end `start.hasValue().not() or end.hasValue().not() or (start <= end)` Mappings rim: n/a v2: DR rim: IVL<TS>[lowClosed="true" and highClosed="true"] or URG<TS>[lowClosed="true" and highClosed="true"] 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	S	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 CodeableConcept Binding XDS Facility Type. IHEXDShealthcareFacilityTypeCode (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD 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	S	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 CodeableConcept Binding Additional details about where the content was created (e.g. clinical specialty). IHEXDSpracticeSettingCode (required) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` Mappings rim: n/a v2: CE/CNE/CWE rim: CD orim: fhir:CodeableConcept rdfs:subClassOf dt:CD fhircomposition: usually from a mapping to a local ValueSet rim: .participation[typeCode="LOC"].role[classCode="DSDLOC"].code xds: DocumentEntry.practiceSettingCode cda: usually from a mapping to a local ValueSet
sourcePatientInfo	I	0..1	Reference(Patient)	There are no (further) constraints on this element Element id DocumentReference.context.sourcePatientInfo Short description Patient demographics from source Definition The Patient Information as known when the document was published. May be a reference to a version specific, or contained. Comments References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Data type Reference(Patient) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) fhircomposition: Composition.subject rim: .participation[typeCode="SBJ"].role[typeCode="PAT"] xds: DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId cda: ClinicalDocument/recordTarget/
related	I	0..*	Reference(Resource)	There are no (further) constraints on this element Element id DocumentReference.context.related Short description Related identifiers or resources Definition Related identifiers or resources associated with the DocumentReference. Comments May be identifiers or resources that caused the DocumentReference or referenced Document to be created. Data type Reference(Resource) Constraints ele-1: All FHIR elements must have a @value or children `hasValue() or (children().count() > id.count())` ref-1: SHALL have a contained resource if a local reference is provided `reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))` Mappings rim: n/a rim: The target of a resource reference is a RIM entry point (Act, Role, or Entity) fhircomposition: Composition.event.detail rim: ./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct] xds: DocumentEntry.referenceIdList cda: ClinicalDocument/relatedDocument

Link Simplifier Profil Übersicht

Anmerkungen zu Must-Support-Feldern

Feldname	Kurzbeschreibung	Hinweise
DocumentReference.masterIdentifier	Versionsspezifische OID des Dokumentes
DocumentReference.masterIdentifier.system	Namensraum des Identifiers	Fix: `urn:ietf:rfc:3986`
DocumentReference.masterIdentifier.value	Wert des Identifiers	OID mit URI-Präfix "urn:oid:". Es sei darauf hingewiesen, dass OIDs auf Basis von UUIDs generiert werden können, ohne einen eigenen Namesraum zu beantragen. Zunächst müssen hierzu alle 128 Bit der UUID in einen Integer-Wert umgerechnet werden. Das Ergebnis muss ohne Bindestriche an die Root-OID '2.25' angehängt werden. Siehe IHE International - Creating Unique IDs - OID and UUID.
DocumentReference.identifier		Abweichend zu MHD V4.0.1 ist die Angabe eines Identifiers in ISiK nicht erforderlich. Ein solcher kann bei Bedarf (z.B. zur Weitergabe des Dokumentes per XDS) erzeugt werden. [Konsens der Arbeitsgruppe vom 12.11.2021] Update für Stufe 3: In MHD 4.2.0 wurde die Verpflichtung zur Angabe eines Identifiers gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.
DocumentReference.status	Status des Dokumentenmetadatensatzes	Der Status des Dokumentes wird in DocumentReference.docStatus gesetzt!
DocumentReference.docStatus	Bearbeitungsstatus des Dokumentes	Abweichend zu MHD V4.0.1 ist die Verwendung von docStatus im ISiK-Kontext erlaubt. Doe Verwendung von docStatus bleibt jedoch optional, da nicht alle Dokumentenerzeugende Systeme einen expliziten Freigabe-Workflow haben. Dokumentenserver müssen jedoch in der Lage sein, den Dokumentenstatus (sofern vorhanden) zu persistieren, anzuzeigen und zu reproduzieren. [Konsens der Arbeitsgruppe vom 10.12.2021]
DocumentReference.type	Dokumententyp	Im ISiK-Kontext ist die Typisierung eines Dokumentes mit Hilfe eines KDL-Codes und des IHE-XDS-Type-Codes erforderlich und ein Server MUSS beide Kodierungen bereitstellen - trotz der Kardinalität DocumentReference.type.coding:XDS 0..1 -, jedoch ist der IHE-XDS-Type-Code bei Übermittlung für Clients nicht verpflichtend (s.u. zu XDS). Während KDL-Codes eine feingranulare Dokumentenklassifikation für die gezielte Suche nach medizinischen und Administrativen Dokumenten ermöglichen, sind IHE-XDS-Type-Codes für den einrichtungsübergreifenden Dokumentenaustausch maßgeblich. Der XDS-Type-Code kann mit Hilfe der bereitgestellten ConceptMaps aus dem KDL-Code ermittelt werden. Weitere Typisierungen (z.B. nach SNOMED oder LOINC) sind uneingeschränkt erlaubt. [Konsens der Arbeitgruppe vom 18.02.2022]. Im Falle, dass der Code 'UNK' entsprechend der ConceptMap verwendet werden soll, MUSS das System 'http://terminology.hl7.org/CodeSystem/v3-NullFlavor' verwendet werden.
DocumentReference.type.coding:KDL	Dokumenttyp gem. KDL-Terminologie
DocumentReference.type.coding:KDL.system	Kodiersystem	Fix: "http://dvmd.de/fhir/CodeSystem/kdl"
DocumentReference.type.coding:KDL.code	Code	Der KDL-Code
DocumentReference.type.coding:KDL.display	Anzeigetext	Der Anzeigetext zum KDL-Code
DocumentReference.type.coding:XDS	Dokumenttyp gem. IHE-De-Terminologie	Die Übermittlung des XDS-Type-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-Type-Code kann über die im Rahmen der KDL-Spezifikation publizierten ConceptMaps aus dem KDL-Code ermittelt werden
DocumentReference.type.coding:XDS.system	Kodiersystem
DocumentReference.type.coding:XDS.code	Code	Der XDS-Type-Code
DocumentReference.type.coding:XDS.display	Anzeigetext	Der Anzeigetext zum XDS-Type-Code
DocumentReference.category	Dokumentklasse/-Kategorie	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.
DocumentReference.category.coding:XDS
DocumentReference.category.coding:XDS.system	Kodiersystem
DocumentReference.category.coding:XDS.code	Code	Der XDS-Class-Code
DocumentReference.category.coding:XDS.display	Anzeigetext	Der Anzeigetext zum XDS-Class-Code
DocumentReference.subject	Patientenbezug des Dokumentes	Im ISIK-Kontext MUSS der referenzierte Patient konform zum ISIKPatient des Basismoduls sein. Für sonstige Kontexte siehe FHIR Kernspezifikation
DocumentReference.subject.reference	Absolute oder relative URL des Patienten auf dem Server	Absolute oder relative URL des Patienten auf dem Server
DocumentReference.author	Autor des Dokumentes	In dieser Ausbaustufe ist die Nennung des Namens oder Kürzels des Autors ausreichend. Eine darüber hinaus gehende Verlinkung auf einen Pracitioner (auflösbar auf dem Server) ist möglich aber nicht erforderlich.
DocumentReference.author.display
DocumentReference.relatesTo		Inbesondere relevant im Kontext von Updates. Bei inhaltlichen Updates MUSS eine `replaces`-Relation angegeben werden.
DocumentReference.description		Genaue menschenlesbare Beschreibung des Dokumentes, z.B. "Lungenfunktionstest vom 18.02.2022"
DocumentReference.securityLabel	Vertraulichkeit	Die Bereitstellung des 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]
DocumentReference.content	Beschreibung des Dokumenteninhaltes	Die Kardinalität wurde angepasst, um den Vorgaben von IHE MHD zu ensprechen [Änderung im Zuge der Kommentierung Stufe 3].
DocumentReference.content.attachment	Anhang
DocumentReference.content.attachment.contentType	Mimetype des Dokumentes	Mimetype (Dateityp) des Dokumentes (z.B. "application/pdf")
DocumentReference.content.attachment.language	Sprache, in der das Dokument verfasst wurde.	Kann bei Systemen, die keine Mehrsprachigkeit unterstützen, fest auf "de" oder "de-DE" gesetzt werden.
DocumentReference.content.attachment.data	Base64-codierte Binärdaten	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.
DocumentReference.content.attachment.url	Referenz auf Dokument	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. 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.
DocumentReference.content.attachment.creation	Dokumentendatum	Es obliegt dem erzeugenden System, zu entscheiden, welches Datum als Dokumentendatum geeignet ist, z.B. Datum der Erstellung oder Datum der letzten Änderung
DocumentReference.content.format	Format des Dokumentes	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"
DocumentReference.context
DocumentReference.context.encounter		Abweichend zu MHD V4.0.1 ist die Verwendung der Encounter-Referenz im ISiK-Kontext erlaubt. `Wird ein Encounter im ISIK-Kontext referenziert, so MUSS dieser konform zum Profil [ISIKKontaktGesundheitseinrichtung](https://gematik.de/fhir/isik/v3/Basismodul/StructureDefinition/ISiKKontaktGesundheitseinrichtung) aus dem Basismodul sein.` Update für Stufe 3: 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.
DocumentReference.context.facilityType	Art der Einrichtung, aus der das Dokument stammt	Kann, sofern keine abweichende Information bekannt ist auf "KHS" gesetzt werden.
DocumentReference.context.practiceSetting		Binding auf IHE-DE Terminologie hinzugefügt

Interaktionen

Für die Ressource DocumentReference MUSS die REST-Interaktion "CREATE" implementiert werden, siehe Interaktion: Dokumentenbereitstellung. Für die Ressource DocumentReference MUSS die REST-Interaktion "READ" implementiert werden, siehe Interaktion: Dokumentenabfrage und -Zugriff.

Folgende Suchparameter sind für das Bestätigungsverfahren relevant, auch in Kombination:

Die in IHE-MHD geltende Einschränkung, dass Clients bei allen Suchen mindestens die Parameter patient oder patient.identifier sowie status verwenden müssen, gilt nicht. Siehe dazu Kapitel Kompatibilität

Der Suchparameter "_id" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?_id=103270

Anwendungshinweise: Weitere Informationen zur Suche nach "_id" finden sich in der FHIR-Basisspezifikation - Abschnitt "Parameters for all resources".
Der Suchparameter "status" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?status=final

Anwendungshinweise: Weitere Informationen zur Suche nach Token-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Clients und Server verpflichend.
Der Suchparameter "patient" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?patient=Patient/123

Anwendungshinweise: Weitere Informationen zur Suche nach Reference-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Clients und Server verpflichend.
Der verkettete Suchparameter "patient.identifier" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?patient.identifier=http://mein-krankenhaus.example/fhir/sid/patienten|1032702

GET [base]/DocumentReference?patient.identifier=1032702

Anwendungshinweise: Weitere Informationen zur Suche nach Token-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Client und Server verpflichtend.

Weitere Informationen zur Suche nach verketteten Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Chained Parameters".
Der Suchparameter "type" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?type=http://dvmd.de/fhir/CodeSystem/kdl|AD010101

Anwendungshinweise: Weitere Informationen zur Suche nach Token-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Server verpflichtend.
Der Suchparameter "category" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?category=http://ihe-d.de/CodeSystem/IHEXDSclassCode|BEF

Anwendungshinweise: Weitere Informationen zur Suche nach Token-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Token Search".

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Server verpflichtend.
Der custom Suchparameter "creation" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?creation=2021-11-05

Anwendungshinweise: Weitere Informationen zur Suche nach Date-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Date Search".

Dieser Suchparameter ist nicht Bestandteil der FHIR-Kernspezifikation und wurde von IHE im Rahmen der MHD-Spezifikation definiert.

Dieser Suchparameter ist für die Umsetzung des IHE MHD Profils für Server verpflichtend.
Der Suchparameter "encounter" MUSS unterstützt werden:

Beispiele:

GET [base]/DocumentReference?encounter=Encounter/123

Anwendungshinweise: Weitere Informationen zur Suche nach Reference-type Parametern finden sich in der FHIR-Basisspezifikation - Abschnitt "Reference Search".

Beispiele

Serverseitiges Dokument (vollständig annotiert)

in XML

<DocumentReference xmlns="http://hl7.org/fhir">
    <id value="dok-beispiel-server" />
    <meta>
        <profile value="https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten" />
        <security>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason" />
            <code value="HTEST" />
        </security>
    </meta>
    <masterIdentifier>
        <system value="urn:ietf:rfc:3986" />
        <value value="urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340" />
    </masterIdentifier>
    <status value="current" />
    <type>
        <coding>
            <system value="http://dvmd.de/fhir/CodeSystem/kdl" />
            <code value="PT130102" />
            <display value="Molekularpathologiebefund" />
        </coding>
        <coding>
            <system value="http://ihe-d.de/CodeSystems/IHEXDStypeCode" />
            <code value="PATH" />
            <display value="Pathologiebefundberichte" />
        </coding>
    </type>
    <category>
        <coding>
            <system value="http://ihe-d.de/CodeSystems/IHEXDSclassCode" />
            <code value="BEF" />
            <display value="Befundbericht" />
        </coding>
    </category>
    <subject>
        <reference value="Patient/PatientinMusterfrau" />
    </subject>
    <description value="Molekularpathologiebefund vom 31.12.21" />
    <securityLabel>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality" />
            <code value="N" />
        </coding>
    </securityLabel>
    <content>
        <attachment>
            <contentType value="application/pdf" />
            <language value="de" />
            <url value="https://mein-Dokumentenserver/dokumente/1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340.pdf" />
            <creation value="2020-12-31T23:50:50-05:00" />
        </attachment>
        <format>
            <system value="http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode" />
            <code value="urn:ihe:iti:xds:2017:mimeTypeSufficient" />
            <display value="mimeType Sufficient" />
        </format>
    </content>
    <context>
        <encounter>
            <reference value="Encounter/BeispielBesuch" />
        </encounter>
        <facilityType>
            <coding>
                <system value="http://ihe-d.de/CodeSystems/PatientBezogenenGesundheitsversorgung" />
                <code value="KHS" />
                <display value="Krankenhaus" />
            </coding>
        </facilityType>
        <practiceSetting>
            <coding>
                <system value="http://ihe-d.de/CodeSystems/AerztlicheFachrichtungen" />
                <code value="ALLG" />
            </coding>
        </practiceSetting>
    </context>
</DocumentReference>

in JSON

{
    "resourceType": "DocumentReference",
    "id": "dok-beispiel-server",
    "meta": {
        "security":  [
            {
                "code": "HTEST",
                "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason"
            }
        ],
        "profile":  [
            "https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten"
        ]
    },
    "masterIdentifier": {
        "system": "urn:ietf:rfc:3986",
        "value": "urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340"
    },
    "type": {
        "coding":  [
            {
                "system": "http://dvmd.de/fhir/CodeSystem/kdl",
                "code": "PT130102",
                "display": "Molekularpathologiebefund"
            },
            {
                "system": "http://ihe-d.de/CodeSystems/IHEXDStypeCode",
                "code": "PATH",
                "display": "Pathologiebefundberichte"
            }
        ]
    },
    "category":  [
        {
            "coding":  [
                {
                    "system": "http://ihe-d.de/CodeSystems/IHEXDSclassCode",
                    "code": "BEF",
                    "display": "Befundbericht"
                }
            ]
        }
    ],
    "status": "current",
    "description": "Molekularpathologiebefund vom 31.12.21",
    "subject": {
        "reference": "Patient/PatientinMusterfrau"
    },
    "securityLabel":  [
        {
            "coding":  [
                {
                    "code": "N",
                    "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality"
                }
            ]
        }
    ],
    "content":  [
        {
            "attachment": {
                "contentType": "application/pdf",
                "url": "https://mein-Dokumentenserver/dokumente/1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340.pdf",
                "language": "de",
                "creation": "2020-12-31T23:50:50-05:00"
            },
            "format": {
                "code": "urn:ihe:iti:xds:2017:mimeTypeSufficient",
                "system": "http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode",
                "display": "mimeType Sufficient"
            }
        }
    ],
    "context": {
        "facilityType": {
            "coding":  [
                {
                    "code": "KHS",
                    "system": "http://ihe-d.de/CodeSystems/PatientBezogenenGesundheitsversorgung",
                    "display": "Krankenhaus"
                }
            ]
        },
        "practiceSetting": {
            "coding":  [
                {
                    "code": "ALLG",
                    "system": "http://ihe-d.de/CodeSystems/AerztlicheFachrichtungen"
                }
            ]
        },
        "encounter":  [
            {
                "reference": "Encounter/BeispielBesuch"
            }
        ]
    }
}

Clientseitiges Dokument (nur mit KDL annotiert)

in XML

<DocumentReference xmlns="http://hl7.org/fhir">
    <id value="dok-beispiel-client-with-binary-pdf-example-short" />
    <meta>
        <profile value="https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten" />
        <security>
            <system value="http://terminology.hl7.org/CodeSystem/v3-ActReason" />
            <code value="HTEST" />
        </security>
    </meta>
    <masterIdentifier>
        <system value="urn:ietf:rfc:3986" />
        <value value="urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340" />
    </masterIdentifier>
    <status value="current" />
    <type>
        <coding>
            <system value="http://dvmd.de/fhir/CodeSystem/kdl" />
            <code value="PT130102" />
            <display value="Molekularpathologiebefund" />
        </coding>
    </type>
    <subject>
        <reference value="Patient/PatientinMusterfrau" />
    </subject>
    <description value="Molekularpathologiebefund vom 31.12.21" />
    <securityLabel>
        <coding>
            <system value="http://terminology.hl7.org/CodeSystem/v3-Confidentiality" />
            <code value="N" />
        </coding>
    </securityLabel>
    <content>
        <attachment>
            <contentType value="application/pdf" />
            <language value="de" />
            <data value="JVBERi0xLjUNJeLjz9MNCjEw" />
            <creation value="2020-12-31T23:50:50-05:00" />
        </attachment>
        <format>
            <system value="http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode" />
            <code value="urn:ihe:iti:xds:2017:mimeTypeSufficient" />
            <display value="mimeType Sufficient" />
        </format>
    </content>
    <context>
        <encounter>
            <reference value="Encounter/BeispielBesuch" />
        </encounter>
        <facilityType>
            <coding>
                <system value="http://ihe-d.de/CodeSystems/PatientBezogenenGesundheitsversorgung" />
                <code value="KHS" />
                <display value="Krankenhaus" />
            </coding>
        </facilityType>
        <practiceSetting>
            <coding>
                <system value="http://ihe-d.de/CodeSystems/AerztlicheFachrichtungen" />
                <code value="ALLG" />
            </coding>
        </practiceSetting>
    </context>
</DocumentReference>

in JSON

{
    "resourceType": "DocumentReference",
    "id": "dok-beispiel-client-with-binary-pdf-example-short",
    "meta": {
        "security":  [
            {
                "code": "HTEST",
                "system": "http://terminology.hl7.org/CodeSystem/v3-ActReason"
            }
        ],
        "profile":  [
            "https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten"
        ]
    },
    "masterIdentifier": {
        "system": "urn:ietf:rfc:3986",
        "value": "urn:oid:1.2.840.113556.1.8000.2554.58783.21864.3474.19410.44358.58254.41281.46340"
    },
    "type": {
        "coding":  [
            {
                "system": "http://dvmd.de/fhir/CodeSystem/kdl",
                "code": "PT130102",
                "display": "Molekularpathologiebefund"
            }
        ]
    },
    "status": "current",
    "description": "Molekularpathologiebefund vom 31.12.21",
    "subject": {
        "reference": "Patient/PatientinMusterfrau"
    },
    "securityLabel":  [
        {
            "coding":  [
                {
                    "code": "N",
                    "system": "http://terminology.hl7.org/CodeSystem/v3-Confidentiality"
                }
            ]
        }
    ],
    "content":  [
        {
            "attachment": {
                "contentType": "application/pdf",
                "data": "JVBERi0xLjUNJeLjz9MNCjEw",
                "language": "de",
                "creation": "2020-12-31T23:50:50-05:00"
            },
            "format": {
                "code": "urn:ihe:iti:xds:2017:mimeTypeSufficient",
                "system": "http://ihe.net/fhir/ihe.formatcode.fhir/CodeSystem/formatcode",
                "display": "mimeType Sufficient"
            }
        }
    ],
    "context": {
        "facilityType": {
            "coding":  [
                {
                    "code": "KHS",
                    "system": "http://ihe-d.de/CodeSystems/PatientBezogenenGesundheitsversorgung",
                    "display": "Krankenhaus"
                }
            ]
        },
        "practiceSetting": {
            "coding":  [
                {
                    "code": "ALLG",
                    "system": "http://ihe-d.de/CodeSystems/AerztlicheFachrichtungen"
                }
            ]
        },
        "encounter":  [
            {
                "reference": "Encounter/BeispielBesuch"
            }
        ]
    }
}