{
"description": "Klinisches Dokument mit zugehörigen Metadaten",
"_filename": "StructureDefinition-mii-pr-dokument-dokument.json",
"package_name": "de.medizininformatikinitiative.kerndatensatz.dokument",
"date": null,
"derivation": "constraint",
"publisher": "Medizininformatik Initiative",
"fhirVersion": "4.0.1",
"name": "MII_PR_Dokument_Dokument",
"abstract": false,
"type": "DocumentReference",
"experimental": null,
"resourceType": "StructureDefinition",
"title": "MII PR Dokument Dokument",
"package_version": "2026.0.0-ballot",
"status": "draft",
"id": "300880c4-eb89-45a4-ae45-6b378ff5e4a4",
"kind": "resource",
"url": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument",
"version": "2026.0.0-ballot",
"differential": {
"element": [ {
"id": "DocumentReference.meta",
"path": "DocumentReference.meta",
"mustSupport": true
}, {
"id": "DocumentReference.meta.profile",
"path": "DocumentReference.meta.profile",
"mustSupport": true
}, {
"path": "DocumentReference.extension",
"min": 0,
"definition": "Status der NLP-Verarbeitung des referenzierten Dokuments",
"short": "NLP Processing Status",
"type": [ {
"code": "Extension",
"profile": [ "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status" ]
} ],
"mustSupport": true,
"sliceName": "nlp-processing-status",
"max": "1",
"id": "DocumentReference.extension:nlp-processing-status"
}, {
"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
}, {
"path": "DocumentReference.identifier",
"definition": "Weitere Dokumente assoziierte Identifikatoren. Die Angabe ist optional [MAY].",
"short": "Weitere Dokumente assoziierte Identifikatoren",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Further document associated Identifiers [MAY]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Further document associated Identifiers"
} ]
} ]
},
"id": "DocumentReference.identifier",
"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"
} ]
} ]
}
}, {
"path": "DocumentReference.status",
"definition": "Zustand des Dokumentenmetadatensatzes. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Zustand des Dokumentenmetadatensatzes",
"_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]."
} ]
} ]
},
"mustSupport": true,
"_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"
} ]
} ]
},
"id": "DocumentReference.status",
"comment": "Typisch: `current`",
"_comment": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Typically: `current`"
} ]
} ]
}
}, {
"path": "DocumentReference.docStatus",
"definition": "Bearbeitungsstatus des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Bearbeitungsstatus des Dokumentes",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Status about the referenced document itself [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Status about the referenced document itself"
} ]
} ]
},
"id": "DocumentReference.docStatus",
"comment": "Typisch: `final`",
"_comment": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Typically: `final`"
} ]
} ]
}
}, {
"path": "DocumentReference.type",
"definition": "Charakterisierung der Dokumentart im Detail. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Charakterisierung der Dokumentart im Detail",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Precise description of the document type [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Precise description of the document type"
} ]
} ]
},
"id": "DocumentReference.type",
"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"
} ]
} ]
}
}, {
"id": "DocumentReference.type.coding",
"path": "DocumentReference.type.coding",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice für Art des verwiesenen Dokument",
"discriminator": [ {
"path": "system",
"type": "value"
} ]
}
}, {
"id": "DocumentReference.type.coding:KDL",
"max": "1",
"min": 0,
"path": "DocumentReference.type.coding",
"binding": {
"strength": "required",
"valueSet": "http://dvmd.de/fhir/ValueSet/kdl"
},
"sliceName": "KDL",
"mustSupport": true
}, {
"id": "DocumentReference.type.coding:KDL.system",
"min": 1,
"path": "DocumentReference.type.coding.system",
"patternUri": "http://dvmd.de/fhir/CodeSystem/kdl"
}, {
"id": "DocumentReference.type.coding:LNC",
"max": "1",
"min": 0,
"path": "DocumentReference.type.coding",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/c80-doc-typecodes"
},
"sliceName": "LNC",
"mustSupport": true
}, {
"id": "DocumentReference.type.coding:LNC.system",
"min": 1,
"path": "DocumentReference.type.coding.system",
"patternUri": "http://loinc.org"
}, {
"id": "DocumentReference.type.coding:SCT",
"max": "1",
"min": 0,
"path": "DocumentReference.type.coding",
"binding": {
"strength": "required",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-typ"
},
"sliceName": "SCT",
"mustSupport": true
}, {
"id": "DocumentReference.type.coding:SCT.system",
"min": 1,
"path": "DocumentReference.type.coding.system",
"patternUri": "http://snomed.info/sct"
}, {
"id": "DocumentReference.type.coding:XDS",
"max": "1",
"min": 0,
"path": "DocumentReference.type.coding",
"binding": {
"strength": "required",
"valueSet": "http://ihe-d.de/ValueSets/IHEXDStypeCode"
},
"sliceName": "XDS",
"mustSupport": true
}, {
"id": "DocumentReference.type.coding:XDS.system",
"min": 1,
"path": "DocumentReference.type.coding.system",
"patternUri": "http://ihe-d.de/CodeSystems/IHEXDStypeCode"
}, {
"path": "DocumentReference.category",
"definition": "Charakterisierung der Dokumentenart in Übersicht. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Charakterisierung der Dokumentenart in Übersicht",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "General description of the document type [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "General description of the document type"
} ]
} ]
},
"id": "DocumentReference.category",
"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"
} ]
} ]
}
}, {
"id": "DocumentReference.category.coding",
"path": "DocumentReference.category.coding",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice für Kategorie des verwiesenen Dokuments",
"discriminator": [ {
"path": "system",
"type": "value"
} ]
}
}, {
"id": "DocumentReference.category.coding:LNC",
"max": "1",
"min": 0,
"path": "DocumentReference.category.coding",
"binding": {
"strength": "required",
"valueSet": "http://hl7.org/fhir/ValueSet/document-classcodes"
},
"sliceName": "LNC",
"mustSupport": true
}, {
"id": "DocumentReference.category.coding:LNC.system",
"min": 1,
"path": "DocumentReference.category.coding.system",
"patternUri": "http://loinc.org"
}, {
"id": "DocumentReference.category.coding:SCT",
"max": "1",
"min": 0,
"path": "DocumentReference.category.coding",
"binding": {
"strength": "required",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-kategorie"
},
"sliceName": "SCT",
"mustSupport": true
}, {
"id": "DocumentReference.category.coding:SCT.system",
"min": 1,
"path": "DocumentReference.category.coding.system",
"patternUri": "http://snomed.info/sct"
}, {
"id": "DocumentReference.category.coding:XDS",
"max": "1",
"min": 0,
"path": "DocumentReference.category.coding",
"binding": {
"strength": "required",
"valueSet": "http://ihe-d.de/ValueSets/IHEXDSclassCode"
},
"sliceName": "XDS",
"mustSupport": true
}, {
"id": "DocumentReference.category.coding:XDS.system",
"min": 1,
"path": "DocumentReference.category.coding.system",
"patternUri": "http://ihe-d.de/CodeSystems/IHEXDSclassCode"
}, {
"id": "DocumentReference.subject",
"path": "DocumentReference.subject",
"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" ]
} ],
"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]."
} ]
} ]
},
"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
}, {
"path": "DocumentReference.relatesTo.code",
"definition": "Beziehung zu anderem Dokument. Die Angabe ist optional [MAY].",
"short": "Beziehung zu anderem Dokument",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Relationship to other document [MAY]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Relationship to other document"
} ]
} ]
},
"id": "DocumentReference.relatesTo.code",
"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"
} ]
} ]
}
}, {
"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
}, {
"path": "DocumentReference.securityLabel",
"definition": "Status über den Sicherheitsbedarf des Dokuments. Die Angabe wird dringend empfohlen [SHALL].",
"short": "Status über den Sicherheitsbedarf des Dokuments",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Security level of the document [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Security level of the document"
} ]
} ]
},
"id": "DocumentReference.securityLabel",
"comment": "Siehe IG Terminologien",
"_comment": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "See IG Terminology"
} ]
} ]
}
}, {
"id": "DocumentReference.content",
"path": "DocumentReference.content",
"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
}, {
"path": "DocumentReference.content.attachment.contentType",
"definition": "MIME-Typ des Dokumenteninhalts. Die Angabe ist dringend empfohlen [SHALL].",
"short": "MIME-Typ des Dokumenteninhalts",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "MIME type of the document content [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "MIME type of the document content"
} ]
} ]
},
"id": "DocumentReference.content.attachment.contentType",
"comment": "Typisch: `text/plain`",
"_comment": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Typically: `text/plain`"
} ]
} ]
}
}, {
"path": "DocumentReference.content.attachment.language",
"definition": "Verwendete Sprache in dem Dokument. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Verwendete Sprache in dem Dokument",
"_definition": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Used language in the document [SHALL]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Used language in the document"
} ]
} ]
},
"id": "DocumentReference.content.attachment.language",
"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`"
} ]
} ]
}
}, {
"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]"
} ]
} ]
},
"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"
} ]
} ]
},
"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]."
} ]
} ]
}
}, {
"path": "DocumentReference.content.attachment.url",
"definition": "Verweis auf den lokalen Ablageort des Dokumentes. Die Angabe ist verpflichtend [MUST], wenn `data` nicht angegeben wurde; ansonsten optional [MAY].",
"short": "Verweis auf den lokalen Ablageort des Dokumentes",
"_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]."
} ]
} ]
},
"mustSupport": true,
"_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"
} ]
} ]
},
"id": "DocumentReference.content.attachment.url",
"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"
} ]
} ]
}
}, {
"path": "DocumentReference.content.attachment.creation",
"definition": "Datum der Erstellung des Dokumentes. Die Angabe ist dringend empfohlen [SHALL].",
"short": "Datum der Erstellung des Dokumentes",
"_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]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Date of the creation of the document"
} ]
} ]
},
"id": "DocumentReference.content.attachment.creation",
"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"
} ]
} ]
}
}, {
"path": "DocumentReference.content.format",
"definition": "Formatangabe, die über den MIME-Typ hinausgehen",
"short": "Komplexe Formatangabe",
"_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"
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Complex format specification"
} ]
} ]
},
"binding": {
"strength": "preferred",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-format-code"
},
"id": "DocumentReference.content.format",
"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"
} ]
} ]
}
}, {
"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",
"type": [ {
"code": "Reference",
"targetProfile": [ "http://hl7.org/fhir/StructureDefinition/Encounter", "https://www.medizininformatik-initiative.de/fhir/core/modul-fall/StructureDefinition/KontaktGesundheitseinrichtung" ]
} ],
"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]."
} ]
} ]
},
"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
}, {
"id": "DocumentReference.context.event.coding",
"path": "DocumentReference.context.event.coding",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice für dokumentierten Vorgang",
"discriminator": [ {
"path": "$this",
"type": "pattern"
} ]
}
}, {
"id": "DocumentReference.context.event.coding:XDS",
"max": "1",
"min": 0,
"path": "DocumentReference.context.event.coding",
"binding": {
"strength": "required",
"valueSet": "http://ihe-d.de/ValueSets/IHEXDSeventCodeList"
},
"sliceName": "XDS",
"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
}, {
"path": "DocumentReference.context.facilityType",
"definition": "Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte. Die Angabe ist optional [MAY].",
"short": "Art der Einrichtung",
"_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]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Type of facility"
} ]
} ]
},
"id": "DocumentReference.context.facilityType",
"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"
} ]
} ]
}
}, {
"id": "DocumentReference.context.facilityType.coding",
"path": "DocumentReference.context.facilityType.coding",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice für Einrichtungsart",
"discriminator": [ {
"path": "$this",
"type": "pattern"
} ]
}
}, {
"id": "DocumentReference.context.facilityType.coding:SCT",
"max": "1",
"min": 0,
"path": "DocumentReference.context.facilityType.coding",
"binding": {
"strength": "required",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-einrichtung"
},
"sliceName": "SCT",
"mustSupport": true
}, {
"id": "DocumentReference.context.facilityType.coding:XDS",
"max": "1",
"min": 0,
"path": "DocumentReference.context.facilityType.coding",
"binding": {
"strength": "required",
"valueSet": "http://ihe-d.de/ValueSets/IHEXDShealthcareFacilityTypeCode"
},
"sliceName": "XDS",
"mustSupport": true
}, {
"path": "DocumentReference.context.practiceSetting",
"definition": "Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde. Die Angabe ist optional [MAY].",
"short": "Klinisches Fachgebiet",
"_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]."
} ]
} ]
},
"mustSupport": true,
"_short": {
"extension": [ {
"url": "http://hl7.org/fhir/StructureDefinition/translation",
"extension": [ {
"url": "lang",
"valueCode": "en"
}, {
"url": "content",
"valueString": "Clinical specialty"
} ]
} ]
},
"id": "DocumentReference.context.practiceSetting",
"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"
} ]
} ]
}
}, {
"id": "DocumentReference.context.practiceSetting.coding",
"path": "DocumentReference.context.practiceSetting.coding",
"slicing": {
"rules": "open",
"ordered": false,
"description": "Slice für IHE XDS-basierte klinische Fachgebiete",
"discriminator": [ {
"path": "$this",
"type": "pattern"
} ]
}
}, {
"id": "DocumentReference.context.practiceSetting.coding:SCT",
"max": "1",
"min": 0,
"path": "DocumentReference.context.practiceSetting.coding",
"binding": {
"strength": "required",
"valueSet": "https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-fachgebiet"
},
"sliceName": "SCT",
"mustSupport": true
}, {
"id": "DocumentReference.context.practiceSetting.coding:XDS",
"max": "1",
"min": 0,
"path": "DocumentReference.context.practiceSetting.coding",
"binding": {
"strength": "required",
"valueSet": "http://ihe-d.de/ValueSets/IHEXDSpracticeSettingCode"
},
"sliceName": "XDS",
"mustSupport": true
} ]
},
"contact": [ {
"telecom": [ {
"value": "https://www.medizininformatik-initiative.de",
"system": "url"
} ]
} ],
"baseDefinition": "http://hl7.org/fhir/StructureDefinition/DocumentReference"
}