{ "resourceType": "StructureDefinition", "id": "mii-pr-dokument-dokument", "url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument", "version": "2027.0.0-ballot.2", "name": "MII_PR_Dokument_Dokument", "title": "MII PR Dokument Dokument", "status": "active", "publisher": "Medizininformatik Initiative", "contact": [ { "telecom": [ { "system": "url", "value": "https://www.medizininformatik-initiative.de" } ] } ], "description": "Klinisches Dokument mit zugehörigen Metadaten", "fhirVersion": "4.0.1", "kind": "resource", "abstract": false, "type": "DocumentReference", "baseDefinition": "http://hl7.org/fhir/StructureDefinition/DocumentReference", "derivation": "constraint", "differential": { "element": [ { "id": "DocumentReference.meta", "path": "DocumentReference.meta", "mustSupport": true }, { "id": "DocumentReference.meta.profile", "path": "DocumentReference.meta.profile", "mustSupport": true }, { "id": "DocumentReference.extension:nlp-processing-status", "path": "DocumentReference.extension", "sliceName": "nlp-processing-status", "short": "NLP Processing Status", "definition": "Status der NLP-Verarbeitung des referenzierten Dokuments", "min": 0, "max": "1", "type": [ { "code": "Extension", "profile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status" ] } ], "mustSupport": true }, { "id": "DocumentReference.masterIdentifier", "path": "DocumentReference.masterIdentifier", "short": "Versionsspezifische OID des Dokuments", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Specific Identifier for this version of the document" } ] } ] }, "definition": "Versionsspezifische OID des Dokuments. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Specific Identifier for this version of the document [SHALL]." } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.identifier", "path": "DocumentReference.identifier", "short": "Weitere Dokumente assoziierte Identifikatoren", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Further document associated Identifiers" } ] } ] }, "definition": "Weitere Dokumente assoziierte Identifikatoren. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Further document associated Identifiers [MAY]." } ] } ] }, "comment": "Z.B. Hausinterne Dokumenten-ID", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "E.g. internal document ID" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.status", "path": "DocumentReference.status", "short": "Zustand des Dokumentenmetadatensatzes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Status about the condition of the document reference" } ] } ] }, "definition": "Zustand des Dokumentenmetadatensatzes. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Status about the condition of the document reference [SHALL]." } ] } ] }, "comment": "Typisch: `current`", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: `current`" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.docStatus", "path": "DocumentReference.docStatus", "short": "Bearbeitungsstatus des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Status about the referenced document itself" } ] } ] }, "definition": "Bearbeitungsstatus des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Status about the referenced document itself [SHALL]." } ] } ] }, "comment": "Typisch: `final`", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: `final`" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.type", "path": "DocumentReference.type", "short": "Charakterisierung der Dokumentart im Detail", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Precise description of the document type" } ] } ] }, "definition": "Charakterisierung der Dokumentart im Detail. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Precise description of the document type [SHALL]." } ] } ] }, "comment": "Empfohlen: KDL und aus KDL abgeleiteter XDS-Type-Code", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Recommended: KDL and from KDL derived XDS-Type-Code" } ] } ] }, "constraint": [ { "key": "mii-iv-dokument-dokument-type", "severity": "warning", "human": "Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein", "expression": "coding.where(system = 'http://dvmd.de/fhir/CodeSystem/kdl').exists() or coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDStypeCode').exists()", "source": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument" } ], "mustSupport": true }, { "id": "DocumentReference.type.coding", "path": "DocumentReference.type.coding", "slicing": { "discriminator": [ { "type": "value", "path": "system" } ], "rules": "open", "description": "Slice für Art des verwiesenen Dokument", "ordered": false }, "min": 1 }, { "id": "DocumentReference.type.coding.system", "path": "DocumentReference.type.coding.system", "min": 1, "mustSupport": true }, { "id": "DocumentReference.type.coding.code", "path": "DocumentReference.type.coding.code", "min": 1, "mustSupport": true }, { "id": "DocumentReference.type.coding:KDL", "path": "DocumentReference.type.coding", "sliceName": "KDL", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://dvmd.de/fhir/ValueSet/kdl" } }, { "id": "DocumentReference.type.coding:KDL.system", "path": "DocumentReference.type.coding.system", "fixedUri": "http://dvmd.de/fhir/CodeSystem/kdl" }, { "id": "DocumentReference.type.coding:LNC", "path": "DocumentReference.type.coding", "sliceName": "LNC", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes" } }, { "id": "DocumentReference.type.coding:LNC.system", "path": "DocumentReference.type.coding.system", "fixedUri": "http://loinc.org" }, { "id": "DocumentReference.type.coding:SCT", "path": "DocumentReference.type.coding", "sliceName": "SCT", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-typ" } }, { "id": "DocumentReference.type.coding:SCT.system", "path": "DocumentReference.type.coding.system", "fixedUri": "http://snomed.info/sct" }, { "id": "DocumentReference.type.coding:XDS", "path": "DocumentReference.type.coding", "sliceName": "XDS", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://ihe-d.de/ValueSets/IHEXDStypeCode" } }, { "id": "DocumentReference.type.coding:XDS.system", "path": "DocumentReference.type.coding.system", "fixedUri": "http://ihe-d.de/CodeSystems/IHEXDStypeCode" }, { "id": "DocumentReference.category", "path": "DocumentReference.category", "short": "Charakterisierung der Dokumentenart in Übersicht", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "General description of the document type" } ] } ] }, "definition": "Charakterisierung der Dokumentenart in Übersicht. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "General description of the document type [SHALL]." } ] } ] }, "comment": "Empfohlen: Aus KDL abgeleiteter XDS-Category-Code", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Recommended: From KDL derived XDS-Category-Code" } ] } ] }, "constraint": [ { "key": "mii-iv-dokument-dokument-category", "severity": "warning", "human": "Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein", "expression": "coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDSclassCode').exists()", "source": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument" } ], "mustSupport": true }, { "id": "DocumentReference.category.coding", "path": "DocumentReference.category.coding", "slicing": { "discriminator": [ { "type": "value", "path": "system" } ], "rules": "open", "description": "Slice für Kategorie des verwiesenen Dokuments", "ordered": false }, "min": 1 }, { "id": "DocumentReference.category.coding.system", "path": "DocumentReference.category.coding.system", "min": 1, "mustSupport": true }, { "id": "DocumentReference.category.coding.code", "path": "DocumentReference.category.coding.code", "min": 1, "mustSupport": true }, { "id": "DocumentReference.category.coding:LNC", "path": "DocumentReference.category.coding", "sliceName": "LNC", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes" } }, { "id": "DocumentReference.category.coding:LNC.system", "path": "DocumentReference.category.coding.system", "fixedUri": "http://loinc.org" }, { "id": "DocumentReference.category.coding:SCT", "path": "DocumentReference.category.coding", "sliceName": "SCT", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-kategorie" } }, { "id": "DocumentReference.category.coding:SCT.system", "path": "DocumentReference.category.coding.system", "fixedUri": "http://snomed.info/sct" }, { "id": "DocumentReference.category.coding:XDS", "path": "DocumentReference.category.coding", "sliceName": "XDS", "min": 0, "max": "1", "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://ihe-d.de/ValueSets/IHEXDSclassCode" } }, { "id": "DocumentReference.category.coding:XDS.system", "path": "DocumentReference.category.coding.system", "fixedUri": "http://ihe-d.de/CodeSystems/IHEXDSclassCode" }, { "id": "DocumentReference.subject", "path": "DocumentReference.subject", "short": "Referenz auf den Patient des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Patient reference to the document" } ] } ] }, "definition": "Referenz auf den Patient des Dokumentes. Die Angabe ist verpflichtend [MUST].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Patient reference to the document [MUST]." } ] } ] }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Patient", "https://www.medizininformatik-initiative.de/fhir/core/modul-person/StructureDefinition/Patient", "https://www.medizininformatik-initiative.de/fhir/core/modul-person/StructureDefinition/PatientPseudonymisiert" ] } ], "mustSupport": true }, { "id": "DocumentReference.relatesTo", "path": "DocumentReference.relatesTo", "short": "Beziehung des Dokuments", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document relationships" } ] } ] }, "definition": "Beziehungen des verwiesenen Dokuments zu anderen Dokumenten.", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document relationships" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.relatesTo.code", "path": "DocumentReference.relatesTo.code", "short": "Beziehung zu anderem Dokument", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Relationship to other document" } ] } ] }, "definition": "Beziehung zu anderem Dokument. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Relationship to other document [MAY]." } ] } ] }, "comment": "Typisch: `appends`, z.B. ergänzende Annotation, oder `transforms`, z.B. Formatwandlung. CAVE: `transforms` meint Dokument wurde transformiert", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: `appends`, e.g. additional annotation, or `transforms`, e.g. format conversion. CAVE: `transforms` means the document was transformed" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.relatesTo.target", "path": "DocumentReference.relatesTo.target", "short": "Referenz auf DocumentReference", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Target of document relations" } ] } ] }, "definition": "Referenz auf DocumentReference. Die Angabe ist verpflichtend [MUST], wenn Beziehungstyp angegeben.", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Target of document relations [MUST], when relationship type is present." } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.description", "path": "DocumentReference.description", "short": "Beschreibung des Inhalts des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Description of the documents content" } ] } ] }, "definition": "Beschreibung des Inhalts des Dokumentes. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Description of the documents content [MAY]." } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.securityLabel", "path": "DocumentReference.securityLabel", "short": "Status über den Sicherheitsbedarf des Dokuments", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Security level of the document" } ] } ] }, "definition": "Status über den Sicherheitsbedarf des Dokuments. Die Angabe wird dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Security level of the document [SHALL]." } ] } ] }, "comment": "Siehe IG Terminologien", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "See IG Terminology" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content", "path": "DocumentReference.content", "slicing": { "discriminator": [ { "type": "exists", "path": "attachment.url" } ], "rules": "open", "description": "Slice für ein Dokument, dessen Lokalisation verlinkt ist", "ordered": false }, "short": "Inhalt des Dokuments", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document content" } ] } ] }, "definition": "Dokument, als Base64-kodierte Daten, oder Verweis, als URL, mit relevanten Metadaten zum Anhang.", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Embedded Base64 encoded document content or URL reference to document." } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content.attachment", "path": "DocumentReference.content.attachment", "short": "Zugang zum Dokument", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Access to the document" } ] } ] }, "definition": "Zugang zum Dokument.", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Access to the document" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "short": "MIME-Typ des Dokumenteninhalts", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "MIME type of the document content" } ] } ] }, "definition": "MIME-Typ des Dokumenteninhalts. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "MIME type of the document content [SHALL]." } ] } ] }, "comment": "Typisch: `text/plain`", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: `text/plain`" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content.attachment.language", "path": "DocumentReference.content.attachment.language", "short": "Verwendete Sprache in dem Dokument", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Used language in the document" } ] } ] }, "definition": "Verwendete Sprache in dem Dokument. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Used language in the document [SHALL]." } ] } ] }, "comment": "Empfohlen: 5-stellige Angabe. Typisch: `de-DE`", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Recommended: 5-digit entry Typically: `de-DE`" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content.attachment.data", "path": "DocumentReference.content.attachment.data", "short": "Dokument als Binärdaten", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document as binary data [Base64]" } ] } ] }, "definition": "Dokument als Binärdaten [Base64]. Die Angabe ist verpflichtend [MUST] für Textausleitungen extern und falls URL nicht angegeben wurde; ansonsten optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document as binary data [Base64] [MUST] for external transfer and when URL not present; otherwise optional [MAY]." } ] } ] }, "comment": "Typisch: Nutzung bei Datentransfer", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: Use for data transfer" } ] } ] } }, { "id": "DocumentReference.content.attachment.url", "path": "DocumentReference.content.attachment.url", "short": "Verweis auf den lokalen Ablageort des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Link to the local location where the document is kept" } ] } ] }, "definition": "Verweis auf den lokalen Ablageort des Dokumentes. Die Angabe ist verpflichtend [MUST], wenn `data` nicht angegeben wurde; ansonsten optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Link to the local location where the document is kept [MUST], when `data` not present; otherwise optional [MAY]." } ] } ] }, "comment": "Typisch: Lokal auflösbare URL", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: Local resolvable URL" } ] } ] } }, { "id": "DocumentReference.content.attachment.creation", "path": "DocumentReference.content.attachment.creation", "short": "Datum der Erstellung des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Date of the creation of the document" } ] } ] }, "definition": "Datum der Erstellung des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Date of the creation of the document [SHALL]." } ] } ] }, "comment": "Bezogen auf letzte Änderung gemäß MII_EX_Dokument_NLP_Processing_Status", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Related to the last change regarding MII_EX_Dokument_NLP_Processing_Status" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.content.format", "path": "DocumentReference.content.format", "short": "Komplexe Formatangabe", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Complex format specification" } ] } ] }, "definition": "Formatangabe, die über den MIME-Typ hinausgehen", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "More complex format specification than the MIME type" } ] } ] }, "comment": "Beinhaltet ValueSets von IHE Deutschland und International", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Contains ValueSets of IHE Germany and International" } ] } ] }, "mustSupport": true, "binding": { "strength": "preferred", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-format-code" } }, { "id": "DocumentReference.content:Binaerdaten", "path": "DocumentReference.content", "sliceName": "Binaerdaten", "min": 0, "max": "*", "mustSupport": true }, { "id": "DocumentReference.content:Binaerdaten.attachment", "path": "DocumentReference.content.attachment", "mustSupport": true }, { "id": "DocumentReference.content:Binaerdaten.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "mustSupport": true }, { "id": "DocumentReference.content:Binaerdaten.attachment.language", "path": "DocumentReference.content.attachment.language", "mustSupport": true }, { "id": "DocumentReference.content:Binaerdaten.attachment.data", "path": "DocumentReference.content.attachment.data", "min": 1 }, { "id": "DocumentReference.content:Binaerdaten.attachment.url", "path": "DocumentReference.content.attachment.url", "max": "0" }, { "id": "DocumentReference.content:Binaerdaten.attachment.creation", "path": "DocumentReference.content.attachment.creation", "mustSupport": true }, { "id": "DocumentReference.content:Binaerdaten.format", "path": "DocumentReference.content.format", "mustSupport": true }, { "id": "DocumentReference.content:Verweis", "path": "DocumentReference.content", "sliceName": "Verweis", "min": 0, "max": "*", "mustSupport": true }, { "id": "DocumentReference.content:Verweis.attachment", "path": "DocumentReference.content.attachment", "mustSupport": true }, { "id": "DocumentReference.content:Verweis.attachment.contentType", "path": "DocumentReference.content.attachment.contentType", "mustSupport": true }, { "id": "DocumentReference.content:Verweis.attachment.language", "path": "DocumentReference.content.attachment.language", "mustSupport": true }, { "id": "DocumentReference.content:Verweis.attachment.data", "path": "DocumentReference.content.attachment.data", "max": "0" }, { "id": "DocumentReference.content:Verweis.attachment.url", "path": "DocumentReference.content.attachment.url", "min": 1 }, { "id": "DocumentReference.content:Verweis.attachment.creation", "path": "DocumentReference.content.attachment.creation", "mustSupport": true }, { "id": "DocumentReference.content:Verweis.format", "path": "DocumentReference.content.format", "mustSupport": true }, { "id": "DocumentReference.context", "path": "DocumentReference.context", "short": "Erzeugungskontext des Dokumentes", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Document creation context" } ] } ] }, "definition": "Klinischer Kontext, in welchem das Dokument erzeugt wurde", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Clinical context in which the document was created" } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.context.encounter", "path": "DocumentReference.context.encounter", "short": "Referenz zum FALL", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Reference to FALL" } ] } ] }, "definition": "Referenz zur semantisch geeignetsten Ebene des Moduls FALL. Die Angabe ist dringend empfohlen [SHALL].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Reference to the semantically most suitable level of the module FALL [SHALL]." } ] } ] }, "type": [ { "code": "Reference", "targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "https://www.medizininformatik-initiative.de/fhir/core/modul-fall/StructureDefinition/KontaktGesundheitseinrichtung" ] } ], "mustSupport": true }, { "id": "DocumentReference.context.event", "path": "DocumentReference.context.event", "short": "Handlungen oder Prozeduren", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Acts or procedures" } ] } ] }, "definition": "Handlungen oder Prozeduren, die im Kontext dokumentiert wurden. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Acts or procedures that were documented in context [MAY]." } ] } ] }, "mustSupport": true, "binding": { "strength": "required", "valueSet": "http://ihe-d.de/ValueSets/IHEXDSeventCodeList" } }, { "id": "DocumentReference.context.event.coding", "path": "DocumentReference.context.event.coding", "min": 1 }, { "id": "DocumentReference.context.event.coding.system", "path": "DocumentReference.context.event.coding.system", "min": 1, "mustSupport": true }, { "id": "DocumentReference.context.event.coding.code", "path": "DocumentReference.context.event.coding.code", "min": 1, "mustSupport": true }, { "id": "DocumentReference.context.period", "path": "DocumentReference.context.period", "short": "Durchführungszeitraum", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Performance period" } ] } ] }, "definition": "Zeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Period during which the act or procedure described in the document was performed [MAY]." } ] } ] }, "mustSupport": true }, { "id": "DocumentReference.context.facilityType", "path": "DocumentReference.context.facilityType", "short": "Art der Einrichtung", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Type of facility" } ] } ] }, "definition": "Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Type of facility where the act or procedure was performed on the patient [MAY]." } ] } ] }, "comment": "Typisch: `KHS` für Krankenhaus", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Typically: `KHS` for hospital" } ] } ] }, "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-einrichtungsart" } }, { "id": "DocumentReference.context.facilityType.coding", "path": "DocumentReference.context.facilityType.coding", "min": 1 }, { "id": "DocumentReference.context.facilityType.coding.system", "path": "DocumentReference.context.facilityType.coding.system", "min": 1, "mustSupport": true }, { "id": "DocumentReference.context.facilityType.coding.code", "path": "DocumentReference.context.facilityType.coding.code", "min": 1, "mustSupport": true }, { "id": "DocumentReference.context.practiceSetting", "path": "DocumentReference.context.practiceSetting", "short": "Klinisches Fachgebiet", "_short": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Clinical specialty" } ] } ] }, "definition": "Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde. Die Angabe ist optional [MAY].", "_definition": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "Clinical specialty in which document content was created [MAY]." } ] } ] }, "comment": "CAVE: Diese Angabe entspricht nicht dem `serviceType` im Modul FALL", "_comment": { "extension": [ { "url": "http://hl7.org/fhir/StructureDefinition/translation", "extension": [ { "url": "lang", "valueCode": "en" }, { "url": "content", "valueString": "CAVE: This specification does not correspond to the `serviceType` in the FALL module" } ] } ] }, "mustSupport": true, "binding": { "strength": "required", "valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-fachgebiet" } }, { "id": "DocumentReference.context.practiceSetting.coding", "path": "DocumentReference.context.practiceSetting.coding", "min": 1 }, { "id": "DocumentReference.context.practiceSetting.coding.system", "path": "DocumentReference.context.practiceSetting.coding.system", "min": 1, "mustSupport": true }, { "id": "DocumentReference.context.practiceSetting.coding.code", "path": "DocumentReference.context.practiceSetting.coding.code", "min": 1, "mustSupport": true } ] } }