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: 33 category: constraint: mii-iv-dokument-dokument-category: {human: 'Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein', source: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument', severity: warning, expression: 'coding.where(system = ''http://ihe-d.de/CodeSystems/IHEXDSclassCode'').exists()'} short: Charakterisierung der Dokumentenart in Übersicht index: 19 _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} elements: coding: index: 20 elements: system: {mustSupport: true, index: 21} code: {mustSupport: true, index: 22} required: [system, code] slicing: rules: open ordered: false description: Slice für Kategorie des verwiesenen Dokuments discriminator: - {path: system, type: value} min: 1 slices: LNC: match: {system: 'http://loinc.org'} schema: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/document-classcodes'} mustSupport: true index: 23 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 24 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: 25 elements: system: pattern: {type: Uri, value: 'http://snomed.info/sct'} index: 26 XDS: match: {system: 'http://ihe-d.de/CodeSystems/IHEXDSclassCode'} schema: binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDSclassCode'} mustSupport: true index: 27 elements: system: pattern: {type: Uri, value: 'http://ihe-d.de/CodeSystems/IHEXDSclassCode'} index: 28 _comment: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en} - {url: content, valueString: 'Recommended: From KDL derived XDS-Category-Code'} required: [coding] 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: 35 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: 36 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: 37 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: 38 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: 39 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} _comment: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en} - {url: content, valueString: 'Typically: Local resolvable URL'} _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].'} index: 40 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: 41 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: 42 slicing: rules: open ordered: false description: Slice für ein Dokument, dessen Lokalisation verlinkt ist discriminator: - {path: attachment.url, type: exists} min: null slices: Binaerdaten: match: {} schema: mustSupport: true array: true index: 43 elements: attachment: mustSupport: true index: 44 elements: contentType: {mustSupport: true, index: 45} language: {mustSupport: true, index: 46} data: {index: 47} url: {index: 48} creation: {mustSupport: true, index: 49} required: [data] format: {mustSupport: true, index: 50} Verweis: match: {} schema: mustSupport: true array: true index: 51 elements: attachment: mustSupport: true index: 52 elements: contentType: {mustSupport: true, index: 53} language: {mustSupport: true, index: 54} data: {index: 55} url: {index: 56} creation: {mustSupport: true, index: 57} required: [url] format: {mustSupport: true, index: 58} type: constraint: mii-iv-dokument-dokument-type: {human: 'Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein', source: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-pr-dokument-dokument', severity: warning, expression: 'coding.where(system = ''http://dvmd.de/fhir/CodeSystem/kdl'').exists() or coding.where(system = ''http://ihe-d.de/CodeSystems/IHEXDStypeCode'').exists()'} short: Charakterisierung der Dokumentart im Detail index: 7 _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} elements: coding: index: 8 elements: system: {mustSupport: true, index: 9} code: {mustSupport: true, index: 10} required: [system, code] slicing: rules: open ordered: false description: Slice für Art des verwiesenen Dokument discriminator: - {path: system, type: value} min: 1 slices: KDL: match: {system: 'http://dvmd.de/fhir/CodeSystem/kdl'} schema: binding: {strength: required, valueSet: 'http://dvmd.de/fhir/ValueSet/kdl'} mustSupport: true index: 11 elements: system: pattern: {type: Uri, value: 'http://dvmd.de/fhir/CodeSystem/kdl'} index: 12 LNC: match: {system: 'http://loinc.org'} schema: binding: {strength: required, valueSet: 'http://hl7.org/fhir/ValueSet/c80-doc-typecodes'} mustSupport: true index: 13 elements: system: pattern: {type: Uri, value: 'http://loinc.org'} index: 14 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: 15 elements: system: pattern: {type: Uri, value: 'http://snomed.info/sct'} index: 16 XDS: match: {system: 'http://ihe-d.de/CodeSystems/IHEXDStypeCode'} schema: binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDStypeCode'} mustSupport: true index: 17 elements: system: pattern: {type: Uri, value: 'http://ihe-d.de/CodeSystems/IHEXDStypeCode'} index: 18 _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'} required: [coding] 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: 30 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: 31 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: 32 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: 59 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: 60 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} binding: {strength: required, valueSet: 'http://ihe-d.de/ValueSets/IHEXDSeventCodeList'} _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: 61 elements: coding: index: 62 elements: system: {mustSupport: true, index: 63} code: {mustSupport: true, index: 64} required: [system, code] required: [coding] 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: 65 facilityType: short: Art der Einrichtung index: 66 _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} elements: coding: index: 67 elements: system: {mustSupport: true, index: 68} code: {mustSupport: true, index: 69} required: [system, code] binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-einrichtungsart'} _comment: extension: - url: http://hl7.org/fhir/StructureDefinition/translation extension: - {url: lang, valueCode: en} - {url: content, valueString: 'Typically: `KHS` for hospital'} required: [coding] practiceSetting: short: Klinisches Fachgebiet index: 70 _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} elements: coding: index: 71 elements: system: {mustSupport: true, index: 72} code: {mustSupport: true, index: 73} required: [system, code] binding: {strength: required, valueSet: 'https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/ValueSet/mii-vs-dokument-fachgebiet'} _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'} required: [coding] 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: 34 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: 29 package_version: 2027.0.0-ballot.rc1 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: 2027.0.0-ballot.rc1