description: Klinisches Dokument mit zugehörigen Metadaten
package_name: de.medizininformatikinitiative.kerndatensatz.dokument
derivation: constraint
name: MII_PR_Dokument_Dokument
type: DocumentReference
elements:
  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:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: 'Description of the documents content [MAY].'}
    mustSupport: true
    index: 29
  category:
    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}
    _comment:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: 'Recommended: From KDL derived XDS-Category-Code'}
    index: 17
    elements:
      coding:
        index: 18
        slicing:
          rules: open
          ordered: false
          description: Slice für Kategorie des verwiesenen Dokuments
          discriminator:
          - {path: system, type: value}
          min: null
          slices:
            LNC:
              match: {system: 'http://loinc.org'}
              schema:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/document-classcodes'}
                mustSupport: true
                index: 19
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://loinc.org'}
                    index: 20
                required: [system]
            SCT:
              match: {system: 'http://snomed.info/sct'}
              schema:
                binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-kategorie'}
                mustSupport: true
                index: 21
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://snomed.info/sct'}
                    index: 22
                required: [system]
            XDS:
              match: {system: 'http://ihe-d.de/CodeSystems/IHEXDSclassCode'}
              schema:
                binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDSclassCode'}
                mustSupport: true
                index: 23
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://ihe-d.de/CodeSystems/IHEXDSclassCode'}
                    index: 24
                required: [system]
  meta:
    mustSupport: true
    index: 0
    elements:
      profile: {mustSupport: true, index: 1}
  docStatus:
    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}
    _comment:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: 'Typically: `final`'}
    index: 6
  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:
      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
    index: 31
    elements:
      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:
          extension:
          - url: http://hl7.org/fhir/StructureDefinition/translation
            extension:
            - {url: lang, valueCode: en}
            - {url: content, valueString: Access to the document}
        mustSupport: true
        index: 32
        elements:
          contentType:
            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}
            _comment:
              extension:
              - url: http://hl7.org/fhir/StructureDefinition/translation
                extension:
                - {url: lang, valueCode: en}
                - {url: content, valueString: 'Typically: `text/plain`'}
            index: 33
          language:
            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}
            _comment:
              extension:
              - url: http://hl7.org/fhir/StructureDefinition/translation
                extension:
                - {url: lang, valueCode: en}
                - {url: content, valueString: 'Recommended: 5-digit entry Typically: `de-DE`'}
            index: 34
          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:
              extension:
              - url: http://hl7.org/fhir/StructureDefinition/translation
                extension:
                - {url: lang, valueCode: en}
                - {url: content, valueString: 'Typically: Use for data transfer'}
            _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].'}
            index: 35
          url:
            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}
            _comment:
              extension:
              - url: http://hl7.org/fhir/StructureDefinition/translation
                extension:
                - {url: lang, valueCode: en}
                - {url: content, valueString: 'Typically: Local resolvable URL'}
            index: 36
          creation:
            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}
            _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}
            index: 37
      format:
        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'}
        _comment:
          extension:
          - url: http://hl7.org/fhir/StructureDefinition/translation
            extension:
            - {url: lang, valueCode: en}
            - {url: content, valueString: Contains ValueSets of IHE Germany and International}
        index: 38
  type:
    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}
    _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'}
    index: 7
    elements:
      coding:
        index: 8
        slicing:
          rules: open
          ordered: false
          description: Slice für Art des verwiesenen Dokument
          discriminator:
          - {path: system, type: value}
          min: null
          slices:
            KDL:
              match: {system: 'http://dvmd.de/fhir/CodeSystem/kdl'}
              schema:
                binding: {strength: required, valueSet: 'http://dvmd.de/fhir/ValueSet/kdl'}
                mustSupport: true
                index: 9
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://dvmd.de/fhir/CodeSystem/kdl'}
                    index: 10
                required: [system]
            LNC:
              match: {system: 'http://loinc.org'}
              schema:
                binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/c80-doc-typecodes'}
                mustSupport: true
                index: 11
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://loinc.org'}
                    index: 12
                required: [system]
            SCT:
              match: {system: 'http://snomed.info/sct'}
              schema:
                binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-typ'}
                mustSupport: true
                index: 13
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://snomed.info/sct'}
                    index: 14
                required: [system]
            XDS:
              match: {system: 'http://ihe-d.de/CodeSystems/IHEXDStypeCode'}
              schema:
                binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDStypeCode'}
                mustSupport: true
                index: 15
                elements:
                  system:
                    pattern: {type: Uri, value: 'http://ihe-d.de/CodeSystems/IHEXDStypeCode'}
                    index: 16
                required: [system]
  extension:
    short: NLP Processing Status
    type: Extension
    mustSupport: true
    url: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status
    index: 2
    slicing:
      slices:
        nlp-processing-status:
          match: {}
          schema: {short: NLP Processing Status, type: Extension, mustSupport: true, url: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status', index: 2}
          min: 0
          max: 1
  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:
      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
    index: 3
  status:
    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}
    _comment:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: 'Typically: `current`'}
    index: 5
  identifier:
    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}
    _comment:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: E.g. internal document ID}
    index: 4
  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:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: Document relationships}
    mustSupport: true
    index: 26
    elements:
      code:
        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}
        _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'}
        index: 27
      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:
          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
        index: 28
  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:
      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
    index: 39
    elements:
      encounter:
        short: Referenz zum FALL
        _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].'}
        refers: ['http://hl7.org/fhir/StructureDefinition/Encounter', 'https://www.medizininformatik-initiative.de/fhir/core/modul-fall/StructureDefinition/KontaktGesundheitseinrichtung']
        type: Reference
        mustSupport: true
        _short:
          extension:
          - url: http://hl7.org/fhir/StructureDefinition/translation
            extension:
            - {url: lang, valueCode: en}
            - {url: content, valueString: Reference to FALL}
        index: 40
      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:
          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
        index: 41
        elements:
          coding:
            index: 42
            slicing:
              rules: open
              ordered: false
              description: Slice für dokumentierten Vorgang
              discriminator:
              - {path: $this, type: pattern}
              min: null
              slices:
                XDS:
                  match: {}
                  schema:
                    binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDSeventCodeList'}
                    mustSupport: true
                    index: 43
                  min: 0
                  max: 1
      period:
        short: Durchführungszeitraum
        _short:
          extension:
          - url: http://hl7.org/fhir/StructureDefinition/translation
            extension:
            - {url: lang, valueCode: en}
            - {url: content, valueString: Performance period}
        _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
        index: 44
      facilityType:
        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}
        _comment:
          extension:
          - url: http://hl7.org/fhir/StructureDefinition/translation
            extension:
            - {url: lang, valueCode: en}
            - {url: content, valueString: 'Typically: `KHS` for hospital'}
        index: 45
        elements:
          coding:
            index: 46
            slicing:
              rules: open
              ordered: false
              description: Slice für Einrichtungsart
              discriminator:
              - {path: $this, type: pattern}
              min: null
              slices:
                SCT:
                  match: {}
                  schema:
                    binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-einrichtung'}
                    mustSupport: true
                    index: 47
                  min: 0
                  max: 1
                XDS:
                  match: {}
                  schema:
                    binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDShealthcareFacilityTypeCode'}
                    mustSupport: true
                    index: 48
                  min: 0
                  max: 1
      practiceSetting:
        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}
        _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'}
        index: 49
        elements:
          coding:
            index: 50
            slicing:
              rules: open
              ordered: false
              description: Slice für IHE XDS-basierte klinische Fachgebiete
              discriminator:
              - {path: $this, type: pattern}
              min: null
              slices:
                SCT:
                  match: {}
                  schema:
                    binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-sct-dokument-fachgebiet'}
                    mustSupport: true
                    index: 51
                  min: 0
                  max: 1
                XDS:
                  match: {}
                  schema:
                    binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDSpracticeSettingCode'}
                    mustSupport: true
                    index: 52
                  min: 0
                  max: 1
  securityLabel:
    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}
    _comment:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: See IG Terminology}
    index: 30
  subject:
    short: Referenz auf den Patient des Dokumentes
    _definition:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: 'Patient reference to the document [MUST].'}
    refers: ['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']
    type: Reference
    mustSupport: true
    _short:
      extension:
      - url: http://hl7.org/fhir/StructureDefinition/translation
        extension:
        - {url: lang, valueCode: en}
        - {url: content, valueString: Patient reference to the document}
    index: 25
package_version: 2026.0.0-ballot
extensions:
  nlp-processing-status: {url: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status', min: 0, max: 1, short: NLP Processing Status, type: Extension, mustSupport: true, index: 2}
class: profile
kind: resource
url: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument
base: http://hl7.org/fhir/StructureDefinition/DocumentReference
version: 2026.0.0-ballot