Rückübermittlung Bericht aus Subsystemen (Composition)
Motivation
In der heterogenen Systemlandschaft im Krankenhaus sind eine Vielzahl spezialisierter Subsysteme im Einsatz. Die Ergebnisse aus diesen Subsystemen sind aktuell jedoch häufig nicht in den Primärsystemen des Krankenhauses verfügbar, denn es bestehen folgende Herausforderungen:
- Die Daten in Subsystemen sind sehr heterogen und können hochspezialisiert sein.
- Bei der Nutzung dieser Subsysteme besteht häufig ein Interesse, auf die menschenlesbare Repräsentation der strukturierten Daten einwirken zu können.
- Künftig ist mit Szenarien zu rechnen, bei denen Befunde aus Subsystemen in eine elektronische Patientenakte übertragen werden sollen.
- Aktuell werden Befunde, obwohl diese in den Subsystemen in hochstrukturierter Form vorliegen, nur als PDF an das Primärsystem zurückübermittelt. Oft weil kein strukturiertes Format spezifiziert ist, das sowohl versendendes Subsystem als auch empfangendes Primärsystem implementiert haben.
- Der Umfang, in dem eine Datenübernahme in ein Primärsystem möglich ist, variiert stark zwischen den Systemen oder Installationen, z.B. abhängig davon, ob ein Modul für Vitalparameter installiert ist.
Die ISiK-Spezifikation begegnet diesen Herausforderungen, indem sie die Rückübermittlung von Ergebnissen aus Subsystemen an die Primärsysteme in Form von strukturierten Dokumenten erfordert, die über eine menschenlesbare Repräsentation verfügen. Diese strukturierten Dokumente werden im ISiK-Kontext als Berichte bezeichnet. Dabei sind die strukturierten Inhalte der Berichte harmonisiert mit den verbreiteten Formaten für Primärsysteme.
In der aktuellen Ausbaustufe von ISiK ist lediglich die Übernahme und Anzeige der Dokument-Metadaten (z.B. Dokumenttyp, Dokumentdatum, Quelle) und der menschenlesbaren HTML-Repräsentation in die Primärsysteme erforderlich.
In weiteren Ausbaustufen von ISiK soll darüber hinaus eine Übernahme der strukturierten Anteile der Dokumente möglich sein, die den ISiK-Spezifikationen entsprechen, z.B. Diagnosen und Prozeduren.
Es obliegt dabei dem Ermessen des Herstellers, ob die Übernahme strukturierter Daten in das Primärsystem automatisch erfolgt, oder durch den Benutzer initiiert wird.
Die Berichte werden, wie von der FHIR Spezifikation für die Composition Ressource vorgesehen, in einem FHIR-Bundle versendet.
Interaktionen
Die Rückübermittlung eines Document-Bundles an ein Primärsystem erfolgt mittels einer 'POST'-Interaktion auf den Endpunkt des Primärsystems.
Beispiele:
POST [base]/
mit einer FHIR-Bundle Ressource im Request-Body.
Anwendungshinweise: Weitere Informationen zu den verschiedenen Endpunkten für Dokumente finden sich in der FHIR-Basisspezifikation - Abschnitt "Document End-Points".
Das Bundle dient der Aggregation aller Ressourcen, die Bestandteil des Dokumentes sind. Dabei ist die erste Ressource im Bundle (Bundle.entry.resource) stets eine Composition, alle weiteren Entries enthalten zusätzliche Ressourcen, auf die die Composition verweist.
Falls die im Dokumenten-Bundle enthaltene Patient-Ressource und/oder Encounter-Ressource nicht anhand der Business-Identifier oder anderer Matching-Kriterien im empfangenden System gefunden werden kann (d.h. der Patient oder der Encounter existiert im empfangenden System noch nicht), MUSS als Antwort der HTTP Status Code "422 - Unprocessable Entity" zurückgegeben werden. Im Body der Response ist eine OperationOutcome zurückzugeben, welche ein Issue mit dem Verweis auf die nicht auflösbare Referenz enthält. Zur Kodierung von OperationOutcome.issue.code MUSS als Code "processing" verwendet werden.
Das Bundle muss folgendem Profil entsprechen:
Bundle | I | Bundle | Element idBundle Contains a collection of resources DefinitionA container for a collection of resources.
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id | Σ | 0..1 | string | There are no (further) constraints on this element Element idBundle.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idBundle.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idBundle.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idBundle.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idBundle.identifier Persistent identifier for the bundle DefinitionA persistent identifier for the bundle that won't change as a bundle is copied from server to server. Persistent identity generally only matters for batches of type Document, Message, and Collection. It would not normally be populated for search and history results and servers ignore Bundle.identifier when processing batches and transactions. For Documents the .identifier SHALL be populated such that the .identifier is globally unique.
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type | S Σ | 1..1 | codeBindingFixed Value | Element idBundle.type document | message | transaction | transaction-response | batch | batch-response | history | searchset | collection DefinitionIndicates the purpose of this bundle - how it is intended to be used. It's possible to use a bundle for other purposes (e.g. a document can be accepted as a transaction). This is primarily defined so that there can be specific rules for some of the bundle types. Indicates the purpose of a bundle - how it is intended to be used.
document
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timestamp | S Σ | 1..1 | instant | There are no (further) constraints on this element Element idBundle.timestamp When the bundle was assembled DefinitionThe date/time that the bundle was assembled - i.e. when the resources were placed in the bundle. For many bundles, the timestamp is equal to .meta.lastUpdated, because they are not stored (e.g. search results). When a bundle is placed in a persistent store, .meta.lastUpdated will be usually be changed by the server. When the bundle is a message, a middleware agent altering the message (even if not stored) SHOULD update .meta.lastUpdated. .timestamp is used to track the original time of the Bundle, and SHOULD be populated. Usage:
The timestamp value should be greater than the lastUpdated and other timestamps in the resources in the bundle, and it should be equal or earlier than the .meta.lastUpdated on the Bundle itself.
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total | Σ I | 0..1 | unsignedInt | There are no (further) constraints on this element Element idBundle.total If search, the total number of matches DefinitionIf a set of search matches, this is the total number of entries of type 'match' across all pages in the search. It does not include search.mode = 'include' or 'outcome' entries and it does not provide a count of the number of entries in the Bundle. Only used if the bundle is a search result set. The total does not include resources such as OperationOutcome and included resources, only the total number of matching resources.
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link | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idBundle.link Links related to this Bundle DefinitionA series of links that provide context to this bundle. Both Bundle.link and Bundle.entry.link are defined to support providing additional context when Bundles are used (e.g. HATEOAS). Bundle.entry.link corresponds to links found in the HTTP header if the resource in the entry was read directly. This specification defines some specific uses of Bundle.link for searching and paging, but no specific uses for Bundle.entry.link, and no defined function in a transaction - the meaning is implementation specific.
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.link.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.link.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.link.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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relation | Σ | 1..1 | string | There are no (further) constraints on this element Element idBundle.link.relation See http://www.iana.org/assignments/link-relations/link-relations.xhtml#link-relations-1 DefinitionA name which details the functional use for this link - see http://www.iana.org/assignments/link-relations/link-relations.xhtml#link-relations-1. Note that FHIR strings SHALL NOT exceed 1MB in size
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url | Σ | 1..1 | uri | There are no (further) constraints on this element Element idBundle.link.url Reference details for the link DefinitionThe reference details for the link. see http://en.wikipedia.org/wiki/Uniform_resource_identifier
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entry | S Σ I | 1..* | BackboneElement | Element idBundle.entry Entry in the bundle - will have a resource or information DefinitionAn entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only). Unordered, Open, by resource(Type) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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link | Σ | 0..* | see (link) | There are no (further) constraints on this element Element idBundle.entry.link Links related to this entry DefinitionA series of links that provide context to this entry. |
fullUrl | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idBundle.entry.fullUrl URI for resource (Absolute URL server address or URI for UUID/OID) DefinitionThe Absolute URL for the resource. The fullUrl SHALL NOT disagree with the id in the resource - i.e. if the fullUrl is not a urn:uuid, the URL shall be version-independent URL consistent with the Resource.id. The fullUrl is a version independent reference to the resource. The fullUrl element SHALL have a value except that:
fullUrl might not be unique in the context of a resource. Note that since FHIR resources do not need to be served through the FHIR API, the fullURL might be a URN or an absolute URL that does not end with the logical id of the resource (Resource.id). However, but if the fullUrl does look like a RESTful server URL (e.g. meets the regex, then the 'id' portion of the fullUrl SHALL end with the Resource.id. Note that the fullUrl is not the same as the canonical URL - it's an absolute url for an endpoint serving the resource (these will happen to have the same value on the canonical server for the resource with the canonical URL).
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resource | S Σ | 1..1 | Resource | There are no (further) constraints on this element Element idBundle.entry.resource A resource in the bundle DefinitionThe Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type.
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search | Σ I | 0..0 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry.search Search related information DefinitionInformation about the search process that lead to the creation of this entry.
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request | Σ I | 0..0 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry.request Additional execution information (transaction/batch/history) DefinitionAdditional information about how this entry should be processed as part of a transaction or batch. For history, it shows how the entry was processed to create the version contained in the entry.
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response | Σ I | 0..0 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry.response Results of execution (transaction/batch/history) DefinitionIndicates the results of processing the corresponding 'request' entry in the batch or transaction being responded to or what the results of an operation where when returning history.
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Composition | S Σ I | 1..1 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry:Composition Entry in the bundle - will have a resource or information DefinitionAn entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only).
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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link | Σ | 0..* | see (link) | There are no (further) constraints on this element Element idBundle.entry:Composition.link Links related to this entry DefinitionA series of links that provide context to this entry. |
fullUrl | Σ | 0..1 | uri | There are no (further) constraints on this element Element idBundle.entry:Composition.fullUrl URI for resource (Absolute URL server address or URI for UUID/OID) DefinitionThe Absolute URL for the resource. The fullUrl SHALL NOT disagree with the id in the resource - i.e. if the fullUrl is not a urn:uuid, the URL shall be version-independent URL consistent with the Resource.id. The fullUrl is a version independent reference to the resource. The fullUrl element SHALL have a value except that:
fullUrl might not be unique in the context of a resource. Note that since FHIR resources do not need to be served through the FHIR API, the fullURL might be a URN or an absolute URL that does not end with the logical id of the resource (Resource.id). However, but if the fullUrl does look like a RESTful server URL (e.g. meets the regex, then the 'id' portion of the fullUrl SHALL end with the Resource.id. Note that the fullUrl is not the same as the canonical URL - it's an absolute url for an endpoint serving the resource (these will happen to have the same value on the canonical server for the resource with the canonical URL).
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resource | Σ I | 0..1 | ISiKBerichtSubSysteme | Element idBundle.entry:Composition.resource A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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search | Σ I | 0..1 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry:Composition.search Search related information DefinitionInformation about the search process that lead to the creation of this entry.
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.search.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.search.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.search.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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mode | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idBundle.entry:Composition.search.mode match | include | outcome - why this is in the result set DefinitionWhy this entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process. There is only one mode. In some corner cases, a resource may be included because it is both a match and an include. In these circumstances, 'match' takes precedence. Why an entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process.
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score | Σ | 0..1 | decimal | There are no (further) constraints on this element Element idBundle.entry:Composition.search.score Search ranking (between 0 and 1) DefinitionWhen searching, the server's search ranking score for the entry. Servers are not required to return a ranking score. 1 is most relevant, and 0 is least relevant. Often, search results are sorted by score, but the client may specify a different sort order. See Patient Match for the EMPI search which relates to this element.
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request | Σ I | 0..1 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry:Composition.request Additional execution information (transaction/batch/history) DefinitionAdditional information about how this entry should be processed as part of a transaction or batch. For history, it shows how the entry was processed to create the version contained in the entry.
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.request.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.request.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.request.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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method | Σ | 1..1 | codeBinding | There are no (further) constraints on this element Element idBundle.entry:Composition.request.method GET | HEAD | POST | PUT | DELETE | PATCH DefinitionIn a transaction or batch, this is the HTTP action to be executed for this entry. In a history bundle, this indicates the HTTP action that occurred. Note that FHIR strings SHALL NOT exceed 1MB in size HTTP verbs (in the HTTP command line). See HTTP rfc for details.
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url | Σ | 1..1 | uri | There are no (further) constraints on this element Element idBundle.entry:Composition.request.url URL for HTTP equivalent of this entry DefinitionThe URL for this entry, relative to the root (the address to which the request is posted). E.g. for a Patient Create, the method would be "POST" and the URL would be "Patient". For a Patient Update, the method would be PUT and the URL would be "Patient/[id]".
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ifNoneMatch | Σ | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.request.ifNoneMatch For managing cache currency DefinitionIf the ETag values match, return a 304 Not Modified status. See the API documentation for "Conditional Read". Note that FHIR strings SHALL NOT exceed 1MB in size
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ifModifiedSince | Σ | 0..1 | instant | There are no (further) constraints on this element Element idBundle.entry:Composition.request.ifModifiedSince For managing cache currency DefinitionOnly perform the operation if the last updated date matches. See the API documentation for "Conditional Read". Note: This is intended for where precisely observed times are required, typically system logs etc., and not human-reported times - for them, see date and dateTime (which can be as precise as instant, but is not required to be) below. Time zone is always required
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ifMatch | Σ | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.request.ifMatch For managing update contention DefinitionOnly perform the operation if the Etag value matches. For more information, see the API section "Managing Resource Contention". Note that FHIR strings SHALL NOT exceed 1MB in size
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ifNoneExist | Σ | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.request.ifNoneExist For conditional creates DefinitionInstruct the server not to perform the create if a specified resource already exists. For further information, see the API documentation for "Conditional Create". This is just the query portion of the URL - what follows the "?" (not including the "?"). Note that FHIR strings SHALL NOT exceed 1MB in size
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response | Σ I | 0..1 | BackboneElement | There are no (further) constraints on this element Element idBundle.entry:Composition.response Results of execution (transaction/batch/history) DefinitionIndicates the results of processing the corresponding 'request' entry in the batch or transaction being responded to or what the results of an operation where when returning history.
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id | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.response.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.response.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idBundle.entry:Composition.response.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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status | Σ | 1..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.response.status Status response code (text optional) DefinitionThe status code returned by processing this entry. The status SHALL start with a 3 digit HTTP code (e.g. 404) and may contain the standard HTTP description associated with the status code. Note that FHIR strings SHALL NOT exceed 1MB in size
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location | Σ | 0..1 | uri | There are no (further) constraints on this element Element idBundle.entry:Composition.response.location The location (if the operation returns a location) DefinitionThe location header created by processing this operation, populated if the operation returns a location. see http://en.wikipedia.org/wiki/Uniform_resource_identifier
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etag | Σ | 0..1 | string | There are no (further) constraints on this element Element idBundle.entry:Composition.response.etag The Etag for the resource (if relevant) DefinitionThe Etag for the resource, if the operation for the entry produced a versioned resource (see Resource Metadata and Versioning and Managing Resource Contention). Etags match the Resource.meta.versionId. The ETag has to match the version id in the header if a resource is included.
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lastModified | Σ | 0..1 | instant | There are no (further) constraints on this element Element idBundle.entry:Composition.response.lastModified Server's date time modified DefinitionThe date/time that the resource was modified on the server. This has to match the same time in the meta header (meta.lastUpdated) if a resource is included.
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outcome | Σ | 0..1 | Resource | There are no (further) constraints on this element Element idBundle.entry:Composition.response.outcome OperationOutcome with hints and warnings (for batch/transaction) DefinitionAn OperationOutcome containing hints and warnings produced as part of processing this entry in a batch or transaction. For a POST/PUT operation, this is the equivalent outcome that would be returned for prefer = operationoutcome - except that the resource is always returned whether or not the outcome is returned. This outcome is not used for error responses in batch/transaction, only for hints and warnings. In a batch operation, the error will be in Bundle.entry.response, and for transaction, there will be a single OperationOutcome instead of a bundle in the case of an error.
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signature | Σ | 0..1 | Signature | There are no (further) constraints on this element Element idBundle.signature Digital Signature DefinitionDigital Signature - base64 encoded. XML-DSig or a JWT. A Signature holds an electronic representation of a signature and its supporting context in a FHIR accessible form. The signature may either be a cryptographic type (XML DigSig or a JWS), which is able to provide non-repudiation proof, or it may be a graphical image that represents a signature or a signature process. This element allows capturing signatures on documents, messages, transactions or even search responses, to support content-authentication, non-repudiation or other business cases. This is primarily relevant where the bundle may travel through multiple hops or via other mechanisms where HTTPS non-repudiation is insufficient. The signature could be created by the "author" of the bundle or by the originating device. Requirements around inclusion of a signature, verification of signatures and treatment of signed/non-signed bundles is implementation-environment specific.
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Unterscheidungshinweis: Informationen zu Interaktionen mit Dokument-Binaries finden sich im Modul ISiK Dokumentenaustausch - Abgrenzung zu ISiK Stufe 2.
Verarbeitung des Dokumentes
Hinweis: Die nachfolgenden Regeln für die Verarbeitung eines Dokumentes gelten nur für Document-Bundles die an den oben genannten Endpunkt gesendet werden. Weitere ISiK-Module können Regeln für die Verarbeitung von anderen Bundle-Typen (z.B. 'transaction') aufstellen.
In der aktuellen Ausbaustufe von ISiK MUSS ein empfangenes Dokument in folgenden Schritten verarbeitet werden:
- Extraktion der Patient-Ressource aus dem Bundle und Herstellung des Patientenbezuges anhand eines eindeutigen Identifiers ('Patient.identifier') oder ähnlich identifizieren Merkmalen
- Extraktion der Encounter.Ressource aus dem Bundle und Herstellung des Fallbezuges anhand der Abrechnungsfallnummer ('Encounter.account.identifier') oder ähnlich identifizieren Merkmalen
- Extraktion der Composition-Ressource aus dem Bundle und Auslesen der mit 'mustSupport' gekennzeichneten Meta-Daten, sowie der menschenlesbaren Repräsentation des Dokumentes ('Composition.text', 'Composition.section.text', 'Composition.section.section.text')
- Hinzufügen des Dokumentes und seiner Metadaten zur Fallakte des Patienten.
- Visualisierung des Dokumentes und seiner Metadaten in der Fallakte des Patienten
Die Grafik zeigt an einem vereinfachten Beispiel die Zuordnung des HTML-Dokumentes zu Patient und Kontakt in der aktuellen Ausbaustufe von ISiK (schwarze Pfeile). Die grauen Pfeile deuten die Übernahme strukturierter Daten, wie sie in weiteren Ausbaustufen erforderlich wird.
Hinweise zum Umgang mit der menschenlesbaren Repräsentation
Die menschenlesbare Repräsentation ("Narrative") eines Dokumentes setzt sich zusammen aus dem Inhalt von 'Composition.text', einer Repräsentation der Metadaten (z.B. Dokumenttyp, Patientenname, Patientennummer, Aufnahmenummer, Datum) sowie der Aggregation der Inhalte von 'Composition.section', wobei zu beachten ist, dass ein Dokument beliebig viele Sections haben kann. Die einzelnen Bestandteile des Narratives KÖNNEN mit <div>-Elementen zusammengefügt werden.
Extraktion der Patient-/ und Encounter-Ressource im Document-Bundle
Folgende Fälle sind zu beachten um eine Patient-/ und Encounter-Ressource aus dem Document-Bundle zu extrahieren:
Die aufzulösende Referenz ist eine URN (immer absolut, z. B. "urn:uuid:9d1714da-b7e6-455b-bfd2-69ce0ff5fb12"):
- Suche nach einem Bundle-Entry mit einer fullUrl, die mit dem reference.value übereinstimmt
- Wenn einer gefunden wird, ist die Auflösung erfolgreich (und endet hier)
- Andernfalls schlägt die Auflösung fehl (und endet hier). Die Referenz hat in dieser Spezifikation keine definierte Bedeutung.
Wenn die Referenz eine absolute URL ist (z. B. "https://fhir.example.org/base/Patient/123", "https://fhir.example.org/base/Patient/123/_history/a"):
- Suche nach einem Bundle-Entry mit einer fullUrl, die mit dem reference.value übereinstimmt
- Wenn einer gefunden wird, ist die Auflösung hier erfolgreich (und endet)
- Wird mehr als ein Eintrag gefunden, KANN der Server nach der neuesten Version suchen (basierend auf meta.lastUpdated). Wenn jener auf diese Weise genau eine aktuelle Version findet, ist die Auflösung erfolgreich (und endet hier)
Wenn die Referenz die Form "[Typ]/[id]" hat (z. B. "Patient/123")
- Wenn der Bundle-Entry, der den Verweis enthält, eine FullUrl hat, die dem RESTful-URL-Regex entspricht (z. B. "https://fhir.example.org/Observation/456"):
- Extrahiert wird die [root] aus der fullUrl des Bundle-Entries und mit der relative Referenz zusammenangefügt (z. B. "https://fhir.example.org/" + "Patient/123" --> "https://fhir.example.org/Patient/123")
- Gefolgt wird den Schritten für die Auflösung absoluter Referenzen. Siehe oben.
- Wenn der Bundle-Entry, der den Verweis enthält, eine FullUrl hat, die dem RESTful-URL-Regex entspricht (z. B. "https://fhir.example.org/Observation/456"):
Persistierung der menschenlesbaren Repräsentation
Das Narrative der Ressource KANN innerhalb einer DocumentReference-Ressource persistiert werden. Zum derzeitigen Zeitpunkt obliegt es der jeweiligen Implementierung wie diese DocumentReference Ressource ausgestaltet ist. Ein Mapping der Composition-Metadaten auf DocumentReference-Metadaten KANN der FHIR Kernspezifikation entnommen werden. Siehe Abschnitt "2.42.8.7 FHIR Composition".
Das Narrative MUSS als Binary-Ressource unter DocumentReference.content.attachment.url angegeben werden.
Hinweis: Es ist zu beachten, dass in einem Attachment-Datentyp im Element "url" eine absolute URL anzugeben ist. Somit muss zunächst das Binary auf dem externen System per POST angelegt werden. Der hieraus resultierende Link kann anschließend im Attachment verwendet werden.
Falls ein Bundle erneut mit dem gleichen Bundle.identifier übermittelt wird, MUSS eine neue DocumentReference erstellt werden, welche unter DocumentReference.relatesTo.target angegeben wird.
Hinweise zum Umgang mit strukturierten Daten
Auch wenn in der aktuellen Stufe nur die Übernahme der menschenlesbaren Repräsentation erforderlich ist, empfiehlt es sich dennoch, das vollständige Bundle samt der strukturierten Anteile zu einem Dokument zu persistieren, sodass zu einem späteren Zeitpunkt, wenn eine Übernahme einzelner Daten möglich ist, diese auch rückwirkend erfolgen kann.
Profil
Name | Canonical |
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ISiKBerichtSubSysteme | https://gematik.de/fhir/isik/v3/Basismodul/StructureDefinition/ISiKBerichtSubSysteme |
Composition | I | Composition | There are no (further) constraints on this element Element idComposition A set of resources composed into a single coherent clinical statement with clinical attestation DefinitionA set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.). While the focus of this specification is on patient-specific clinical statements, this resource can also apply to other healthcare-related statements such as study protocol designs, healthcare invoices and other activities that are not necessarily patient-specific or clinical.
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id | S Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.id Logical id of this artifact DefinitionThe logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes. The only time that a resource does not have an id is when it is being submitted to the server using a create operation. |
meta | Σ | 0..1 | Meta | There are no (further) constraints on this element Element idComposition.meta Metadata about the resource DefinitionThe metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.
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implicitRules | Σ ?! | 0..1 | uri | There are no (further) constraints on this element Element idComposition.implicitRules A set of rules under which this content was created DefinitionA reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc. Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.
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language | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.language Language of the resource content DefinitionThe base language in which the resource is written. Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute). A human language.
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text | S | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.text Text summary of the resource, for human interpretation Alternate namesnarrative, html, xhtml, display DefinitionA human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety. Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.text.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.text.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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status | S | 1..1 | codeBindingFixed Value | Element idComposition.text.status generated | extensions | additional | empty DefinitionThe status of the narrative - whether it's entirely generated (from just the defined data or the extensions too), or whether a human authored it and it may contain additional data. Note that FHIR strings SHALL NOT exceed 1MB in size The status of a resource narrative.
extensions
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div | S I | 1..1 | xhtml | There are no (further) constraints on this element Element idComposition.text.div Limited xhtml content DefinitionThe actual narrative content, a stripped down version of XHTML. The contents of the html element are an XHTML fragment containing only the basic html formatting elements described in chapters 7-11 and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained stylesheets. The XHTML content SHALL NOT contain a head, a body, external stylesheet references, scripts, forms, base/link/xlink, frames, iframes and objects.
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contained | 0..* | Resource | There are no (further) constraints on this element Element idComposition.contained Contained, inline Resources Alternate namesinline resources, anonymous resources, contained resources DefinitionThese resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope. This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.modifierExtension Extensions that cannot be ignored Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the resource and that modifies the understanding of the element that contains it and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer is allowed to define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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identifier | S Σ | 1..1 | Identifier | There are no (further) constraints on this element Element idComposition.identifier Version-independent identifier for the Composition DefinitionA version-independent identifier for the Composition. This identifier stays constant as the composition is changed over time. Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.identifier.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.identifier.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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use | Σ ?! | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.identifier.use usual | official | temp | secondary | old (If known) DefinitionThe purpose of this identifier. Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary. Identifies the purpose for this identifier, if known .
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type | Σ | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.identifier.type Description of identifier DefinitionA coded type for the identifier that can be used to determine which identifier to use for a specific purpose. Allows users to make use of identifiers when the identifier system is not known. This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage. Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type. A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
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system | S Σ | 1..1 | uri | There are no (further) constraints on this element Element idComposition.identifier.system The namespace for the identifier value DefinitionEstablishes the namespace for the value - that is, a URL that describes a set values that are unique. There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers. Identifier.system is always case sensitive.
General http://www.acme.com/identifiers/patient Mappings
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value | S Σ | 1..1 | string | There are no (further) constraints on this element Element idComposition.identifier.value The value that is unique DefinitionThe portion of the identifier typically relevant to the user and which is unique within the context of the system. If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension. Identifier.value is to be treated as case sensitive unless knowledge of the Identifier.system allows the processer to be confident that non-case-sensitive processing is safe.
General 123456 Mappings
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idComposition.identifier.period Time period when id is/was valid for use DefinitionTime period during which identifier is/was valid for use. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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assigner | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.identifier.assigner Organization that issued id (may be just text) DefinitionOrganization that issued/manages the identifier. The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.
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status | S Σ ?! | 1..1 | codeBindingFixed Value | Element idComposition.status preliminary | final | amended | entered-in-error DefinitionThe workflow/clinical status of this composition. The status is a marker for the clinical standing of the document. Need to be able to mark interim, amended, or withdrawn compositions or documents. If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag "entered-in-error" is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required. The workflow/clinical status of the composition.
final
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type | S Σ | 1..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.type Kind of composition (LOINC if possible) DefinitionSpecifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition. Key metadata element describing the composition, used in searching/filtering. For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding. Type of a composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 1..* | Coding | Element idComposition.type.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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LOINC | S Σ | 0..1 | CodingPattern | Element idComposition.type.coding:LOINC Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://loinc.org", "code": "55112-7" }
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uriFixed Value | Element idComposition.type.coding:LOINC.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.org
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | codeFixed Value | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
55112-7
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idComposition.type.coding:LOINC.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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KDL | S Σ | 0..1 | CodingPattern | Element idComposition.type.coding:KDL Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://dvmd.de/fhir/CodeSystem/kdl" }
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:KDL.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.coding:KDL.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uriFixed Value | Element idComposition.type.coding:KDL.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://dvmd.de/fhir/CodeSystem/kdl
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:KDL.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ I | 1..1 | code | Element idComposition.type.coding:KDL.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:KDL.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idComposition.type.coding:KDL.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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IHE | S Σ | 0..1 | CodingPattern | Element idComposition.type.coding:IHE Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
{ "system": "http://ihe-d.de/CodeSystems/IHEXDStypeCode" }
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:IHE.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.type.coding:IHE.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uriFixed Value | Element idComposition.type.coding:IHE.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://ihe-d.de/CodeSystems/IHEXDStypeCode
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:IHE.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idComposition.type.coding:IHE.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.coding:IHE.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idComposition.type.coding:IHE.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.type.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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category | S Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idComposition.category Categorization of Composition DefinitionA categorization for the type of the composition - helps for indexing and searching. This may be implied by or derived from the code specified in the Composition Type. Helps humans to assess whether the composition is of interest when viewing an index of compositions or documents. This is a metadata field from XDS/MHD. High-level kind of a clinical document at a macro level.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.category.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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coding | S Σ | 0..* | Coding | Element idComposition.category.coding Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true. Unordered, Open, by $this(Pattern) Constraints
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LOINC | S Σ | 0..1 | Coding | There are no (further) constraints on this element Element idComposition.category.coding:LOINC Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uriFixed Value | Element idComposition.category.coding:LOINC.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://loinc.org
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idComposition.category.coding:LOINC.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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IHE | S Σ | 0..1 | Coding | There are no (further) constraints on this element Element idComposition.category.coding:IHE Code defined by a terminology system DefinitionA reference to a code defined by a terminology system. Allows for alternative encodings within a code system, and translations to other code systems. Codes may be defined very casually in enumerations, or code lists, up to very formal definitions such as SNOMED CT - see the HL7 v3 Core Principles for more information. Ordering of codings is undefined and SHALL NOT be used to infer meaning. Generally, at most only one of the coding values will be labeled as UserSelected = true.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:IHE.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.category.coding:IHE.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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system | Σ | 1..1 | uriFixed Value | Element idComposition.category.coding:IHE.system Identity of the terminology system DefinitionThe identification of the code system that defines the meaning of the symbol in the code. Need to be unambiguous about the source of the definition of the symbol. The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.
http://ihe-d.de/CodeSystems/IHEXDSclassCode
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version | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:IHE.version Version of the system - if relevant DefinitionThe version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged. Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.
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code | Σ | 1..1 | code | There are no (further) constraints on this element Element idComposition.category.coding:IHE.code Symbol in syntax defined by the system DefinitionA symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination). Need to refer to a particular code in the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.coding:IHE.display Representation defined by the system DefinitionA representation of the meaning of the code in the system, following the rules of the system. Need to be able to carry a human-readable meaning of the code for readers that do not know the system. Note that FHIR strings SHALL NOT exceed 1MB in size
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userSelected | Σ | 0..1 | boolean | There are no (further) constraints on this element Element idComposition.category.coding:IHE.userSelected If this coding was chosen directly by the user DefinitionIndicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays). This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing. Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.
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text | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.category.text Plain text representation of the concept DefinitionA human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user. The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source. Very often the text is the same as a displayName of one of the codings.
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subject | S Σ I | 1..1 | Reference(Patient) | Element idComposition.subject Who and/or what the composition is about DefinitionWho or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). Essential metadata for searching for the composition. Identifies who and/or what the composition/document is about. For clinical documents, this is usually the patient.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.subject.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.subject.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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reference | S Σ I | 1..1 | string | There are no (further) constraints on this element Element idComposition.subject.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idComposition.subject.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idComposition.subject.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | Σ | 0..1 | string | There are no (further) constraints on this element Element idComposition.subject.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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encounter | S Σ I | 0..1 | Reference(Encounter) | There are no (further) constraints on this element Element idComposition.encounter Context of the Composition DefinitionDescribes the clinical encounter or type of care this documentation is associated with. Provides context for the composition and supports searching. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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date | S Σ | 1..1 | dateTime | There are no (further) constraints on this element Element idComposition.date Composition editing time DefinitionThe composition editing time, when the composition was last logically changed by the author. dateTime is used for tracking, organizing versions and searching. Note that this is the time of authoring. When packaged in a document, Bundle.timestamp is the date of packaging. The Last Modified Date on the composition may be after the date of the document was attested without being changed.
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author | S Σ I | 1..* | Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) | Element idComposition.author Who and/or what authored the composition DefinitionIdentifies who is responsible for the information in the composition, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Constraints
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.author.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.author.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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reference | Σ I | 0..1 | string | There are no (further) constraints on this element Element idComposition.author.reference Literal reference, Relative, internal or absolute URL DefinitionA reference to a location at which the other resource is found. The reference may be a relative reference, in which case it is relative to the service base URL, or an absolute URL that resolves to the location where the resource is found. The reference may be version specific or not. If the reference is not to a FHIR RESTful server, then it should be assumed to be version specific. Internal fragment references (start with '#') refer to contained resources. Using absolute URLs provides a stable scalable approach suitable for a cloud/web context, while using relative/logical references provides a flexible approach suitable for use when trading across closed eco-system boundaries. Absolute URLs do not need to point to a FHIR RESTful server, though this is the preferred approach. If the URL conforms to the structure "/[type]/[id]" then it should be assumed that the reference is to a FHIR RESTful server.
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type | Σ | 0..1 | uriBinding | There are no (further) constraints on this element Element idComposition.author.type Type the reference refers to (e.g. "Patient") DefinitionThe expected type of the target of the reference. If both Reference.type and Reference.reference are populated and Reference.reference is a FHIR URL, both SHALL be consistent. The type is the Canonical URL of Resource Definition that is the type this reference refers to. References are URLs that are relative to http://hl7.org/fhir/StructureDefinition/ e.g. "Patient" is a reference to http://hl7.org/fhir/StructureDefinition/Patient. Absolute URLs are only allowed for logical models (and can only be used in references in logical models, not resources). This element is used to indicate the type of the target of the reference. This may be used which ever of the other elements are populated (or not). In some cases, the type of the target may be determined by inspection of the reference (e.g. a RESTful URL) or by resolving the target of the reference; if both the type and a reference is provided, the reference SHALL resolve to a resource of the same type as that specified. Aa resource (or, for logical models, the URI of the logical model).
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identifier | Σ | 0..1 | Identifier | There are no (further) constraints on this element Element idComposition.author.identifier Logical reference, when literal reference is not known DefinitionAn identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference. When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy. When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it. Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).
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display | S Σ | 1..1 | string | There are no (further) constraints on this element Element idComposition.author.display Text alternative for the resource DefinitionPlain text narrative that identifies the resource in addition to the resource reference. This is generally not the same as the Resource.text of the referenced resource. The purpose is to identify what's being referenced, not to fully describe it.
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title | S Σ | 1..1 | string | There are no (further) constraints on this element Element idComposition.title Human Readable name/title DefinitionOfficial human-readable label for the composition. For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a "consultation" or "progress note"). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.
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confidentiality | Σ | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.confidentiality As defined by affinity domain DefinitionThe code specifying the level of confidentiality of the Composition. The exact use of this element, and enforcement and issues related to highly sensitive documents are out of scope for the base specification, and delegated to implementation profiles (see security section). This element is labeled as a modifier because highly confidential documents must not be treated as if they are not. Codes specifying the level of confidentiality of the composition.
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attester | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.attester Attests to accuracy of composition DefinitionA participant who has attested to the accuracy of the composition/document. Identifies responsibility for the accuracy of the composition content. Only list each attester once.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.attester.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.attester.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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mode | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.attester.mode personal | professional | legal | official DefinitionThe type of attestation the authenticator offers. Indicates the level of authority of the attestation. Note that FHIR strings SHALL NOT exceed 1MB in size The way in which a person authenticated a composition.
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time | 0..1 | dateTime | There are no (further) constraints on this element Element idComposition.attester.time When the composition was attested DefinitionWhen the composition was attested by the party. Identifies when the information in the composition was deemed accurate. (Things may have changed since then.).
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party | I | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | There are no (further) constraints on this element Element idComposition.attester.party Who attested the composition DefinitionWho attested the composition in the specified way. Identifies who has taken on the responsibility for accuracy of the composition content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Constraints
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custodian | Σ I | 0..1 | Reference(Organization) | There are no (further) constraints on this element Element idComposition.custodian Organization which maintains the composition DefinitionIdentifies the organization or group who is responsible for ongoing maintenance of and access to the composition/document information. Identifies where to go to find the current version, where to report issues, etc. This is useful when documents are derived from a composition - provides guidance for how to get the latest version of the document. This is optional because this is sometimes not known by the authoring system, and can be inferred by context. However, it is important that this information be known when working with a derived document, so providing a custodian is encouraged.
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relatesTo | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.relatesTo Relationships to other compositions/documents DefinitionRelationships that this composition has with other compositions or documents that already exist. A document is a version specific composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.relatesTo.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.relatesTo.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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code | 1..1 | codeBinding | There are no (further) constraints on this element Element idComposition.relatesTo.code replaces | transforms | signs | appends DefinitionThe type of relationship that this composition has with anther composition or document. If this document appends another document, then the document cannot be fully understood without also accessing the referenced document. The type of relationship between documents.
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target[x] | 1..1 | There are no (further) constraints on this element Element idComposition.relatesTo.target[x] Target of the relationship DefinitionThe target composition/document of this relationship.
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targetIdentifier | Identifier | There are no (further) constraints on this element Data type | ||
targetReference | Reference(Composition) | There are no (further) constraints on this element Data type | ||
event | Σ | 0..* | BackboneElement | There are no (further) constraints on this element Element idComposition.event The clinical service(s) being documented DefinitionThe clinical service, such as a colonoscopy or an appendectomy, being documented. Provides context for the composition and creates a linkage between a resource describing an event and the composition created describing the event. The event needs to be consistent with the type element, though can provide further information if desired.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.event.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.event.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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code | Σ | 0..* | CodeableConcept | There are no (further) constraints on this element Element idComposition.event.code Code(s) that apply to the event being documented DefinitionThis list of codes represents the main clinical acts, such as a colonoscopy or an appendectomy, being documented. In some cases, the event is inherent in the typeCode, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act. An event can further specialize the act inherent in the typeCode, such as where it is simply "Procedure Report" and the procedure was a "colonoscopy". If one or more eventCodes are included, they SHALL NOT conflict with the values inherent in the classCode, practiceSettingCode or typeCode, as such a conflict would create an ambiguous situation. This short list of codes is provided to be used as key words for certain types of queries. This list of codes represents the main clinical acts being documented.
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period | Σ I | 0..1 | Period | There are no (further) constraints on this element Element idComposition.event.period The period covered by the documentation DefinitionThe period of time covered by the documentation. There is no assertion that the documentation is a complete representation for this period, only that it documents events during this time. A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration.
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detail | Σ I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.event.detail The event(s) being documented DefinitionThe description and/or reference of the event(s) being documented. For example, this could be used to document such a colonoscopy or an appendectomy. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository.
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section | S I | 1..* | BackboneElement | There are no (further) constraints on this element Element idComposition.section Composition is broken into sections DefinitionThe root of the sections that make up the composition.
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id | 0..1 | string | There are no (further) constraints on this element Element idComposition.section.id Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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extension | I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.extension Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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modifierExtension | Σ ?! I | 0..* | Extension | There are no (further) constraints on this element Element idComposition.section.modifierExtension Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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title | S | 1..1 | string | There are no (further) constraints on this element Element idComposition.section.title Label for section (e.g. for ToC) Alternate namesheader, label, caption DefinitionThe label for this particular section. This will be part of the rendered content for the document, and is often used to build a table of contents. Section headings are often standardized for different types of documents. They give guidance to humans on how the document is organized. The title identifies the section for a human reader. The title must be consistent with the narrative of the resource that is the target of the section.content reference. Generally, sections SHOULD have titles, but in some documents, it is unnecessary or inappropriate. Typically, this is where a section has subsections that have their own adequately distinguishing title, or documents that only have a single section. Most Implementation Guides will make section title to be a required element.
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code | 0..1 | CodeableConcept | There are no (further) constraints on this element Element idComposition.section.code Classification of section (recommended) DefinitionA code identifying the kind of content contained within the section. This must be consistent with the section title. Provides computable standardized labels to topics within the document. The code identifies the section for an automated processor of the document. This is particularly relevant when using profiles to control the structure of the document. If the section has content (instead of sub-sections), the section.code does not change the meaning or interpretation of the resource that is the content of the section in the comments for the section.code. Classification of a section of a composition/document.
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author | I | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | There are no (further) constraints on this element Element idComposition.section.author Who and/or what authored the section DefinitionIdentifies who is responsible for the information in this section, not necessarily who typed it in. Identifies who is responsible for the content. References SHALL be a reference to an actual FHIR resource, and SHALL be resolveable (allowing for access control, temporary unavailability, etc.). Resolution can be either by retrieval from the URL, or, where applicable by resource type, by treating an absolute reference as a canonical URL and looking it up in a local registry/repository. Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Constraints
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focus | I | 0..1 | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.focus Who/what the section is about, when it is not about the subject of composition DefinitionThe actual focus of the section when it is not the subject of the composition, but instead represents something or someone associated with the subject such as (for a patient subject) a spouse, parent, fetus, or donor. If not focus is specified, the focus is assumed to be focus of the parent section, or, for a section in the Composition itself, the subject of the composition. Sections with a focus SHALL only include resources where the logical subject (patient, subject, focus, etc.) matches the section focus, or the resources have no logical subject (few resources). Typically, sections in a doument are about the subject of the document, whether that is a patient, or group of patients, location, or device, or whatever. For some kind of documents, some sections actually contain data about related entities. Typical examples are a section in a newborn discharge summary concerning the mother, or family history documents, with a section about each family member, though there are many other examples.
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text | S I | 1..1 | Narrative | There are no (further) constraints on this element Element idComposition.section.text Text summary of the section, for human interpretation DefinitionA human-readable narrative that contains the attested content of the section, used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Document profiles may define what content should be represented in the narrative to ensure clinical safety.
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mode | 0..1 | codeBinding | There are no (further) constraints on this element Element idComposition.section.mode working | snapshot | changes DefinitionHow the entry list was prepared - whether it is a working list that is suitable for being maintained on an ongoing basis, or if it represents a snapshot of a list of items from another source, or whether it is a prepared list where items may be marked as added, modified or deleted. Sections are used in various ways, and it must be known in what way it is safe to use the entries in them. This element is labeled as a modifier because a change list must not be misunderstood as a complete list. The processing mode that applies to this section.
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orderedBy | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.orderedBy Order of section entries DefinitionSpecifies the order applied to the items in the section entries. Important for presentation and rendering. Lists may be sorted to place more important information first or to group related entries. Applications SHOULD render ordered lists in the order provided, but MAY allow users to re-order based on their own preferences as well. If there is no order specified, the order is unknown, though there may still be some order. What order applies to the items in the entry.
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entry | I | 0..* | Reference(Resource) | There are no (further) constraints on this element Element idComposition.section.entry A reference to data that supports this section DefinitionA reference to the actual resource from which the narrative in the section is derived. If there are no entries in the list, an emptyReason SHOULD be provided.
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emptyReason | I | 0..1 | CodeableConceptBinding | There are no (further) constraints on this element Element idComposition.section.emptyReason Why the section is empty DefinitionIf the section is empty, why the list is empty. An empty section typically has some text explaining the empty reason. Allows capturing things like "none exist" or "not asked" which can be important for most lists. The various reasons for an empty section make a significant interpretation to its interpretation. Note that this code is for use when the entire section content has been suppressed, and not for when individual items are omitted - implementers may consider using a text note or a flag on an entry in these cases. If a section is empty, why it is empty.
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section | S I | 0..* | see (section) | There are no (further) constraints on this element Element idComposition.section.section Nested Section DefinitionA nested sub-section within this section. Nested sections are primarily used to help human readers navigate to particular portions of the document.
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Anmerkungen zu den Must-Support-Feldern
Composition.id
Bedeutung: Subsystem-interne Datensatz-ID
Composition.profile
Bedeutung: Erklärung zur Konformität zum ISiK-Profil
Composition.text
Bedeutung: menschenlesbare Repräsentation des Dokumentenkopfes (Metadaten)
Hinweise: Die Mindestanforderungen an den Inhalt der menschenlesbaren Repräsentation umfasst folgende Informationen:
- Composition.subject:Patient.name.family
- Composition.subject:Patient.birthDate
- Composition.subject:Patient.identifier:pid
- Composition.status
- Composition.type.text
- Composition.date
- Composition.title
- Composition.author.display
Composition.identifier
Bedeutung: Subsystem-seitig zugewiesener Identifier des Berichtes mit Angabe der URL des vom Subsystem verwendeten Namensraumes
Hinweise: Werden eigene Identifier bzw. NamingSystems verwendet, so sei auf den Leitfaden der Basisprofile Deutschland (HL7 Deutschland) zu den Best-Practices bei Namensräumen verwiesen.
Dazu ein Beispiel für einen Identifier eines Sub-System-Berichts:
<identifier> <system value="https://fhir.krankenhaus.example/sid/system-a/berichtnummer" /> <value value="0123456789" /> </identifier>
Die Verwendung von OIDs ist möglich, wird jedoch nicht empfohlen. Für die Verwendnung von OIDs KANN folgendes Format verwendet werden:
- Das Feld
system
enthält den festen Wert "urn:ietf:rfc:3986" - Das Feld
value
enthält die OID mit dem Präfix "urn:oid:"
Beispiel:
<identifier> <system value="urn:ietf:rfc:3986"/> <value value="urn:oid:2.16.840.1.113883.6.96"/> </identifier>
Composition.status
Bedeutung: Status des Dokumentes
Composition.type
Bedeutung: Dokumenttyp
Hinweise: In der aktuellen Ausbaustufe von ISiK ist textuelle Repräsentation des Dokumenttyps (type.text
) ausreichend. Die darüber hinausgehende Codierung des Dokumenttyps (z.B. mit LOINC, IHE-Typecodes oder KDL) in type.coding
KANN implementiert werden
Composition.subject
Bedeutung: Patientenbezug des Dokumentes
Composition.encounter
Bedeutung: Fallbezug des Dokumentes
Composition.date
Bedeutung: Datum der letzten Änderung am Dokument
Composition.author.display
Bedeutung: Autor des Dokumentes (Person, Subsystem)
Hinweise: In der aktuellen Ausbaustufe von ISiK ist die Verwendung der textuellen Repräsentation (display) von Autor und Subsystem ausreichend. Die darüber hinaus gehende Verlinkung auf Practitioner bzw. Device-Ressourcen KANN implementiert werden.
Composition.title
Bedeutung: Dokumentenbezeichnung
Hinweise: Die Dokumentenbezeichnung dient der Darstellung des Dokumentes in einer Übersicht, z.B. in einer Patientenakte, und KANN der schnellen Auffindbarkeit eines gesuchten Dokumentes dienen. Geeignete Bezeichnungen sind zum Beispiel
- "Kleines Blutbild vom 13.10.2020"
- "Pathologiebefund (Abstrich) vom 13.10.2020"
- "Blutgasmessung vom 13.10.2020 14:14h"
Composition.section.title
Bedeutung: Kapitelüberschrift
Composition.section.text
Bedeutung: menschenlesbare Repräsentation des Inhalts eines Kapitels
Hinweise: Für Aggregation einer vollständigen menschenlesbaren Repräsentation MÜSSEN die Repräsentationen der einzelnen Kapitel an die Repräsentation der Metadaten (Composition.text
) angehängt werden. Für die Separierung KÖNNEN einfache <div>-Tags verwendet werden.
Es ist zu beachten, dass Kapitel auch Unterkapitel enthalten KÖNNEN (Composition.section.section
), die bei der Aggregation entsprechend berücksichtigt werden MÜSSEN.
Die Mindestanforderungen an den Inhalt der menschenlesbaren Repräsentation umfasst folgende Informationen:
section.title
+ Freitext odersection.title
+Resource.text
der referenzierten Ressource odersection.title
+ eine aggregierte Repräsentation vonResource.text
wenn in einer Section mehrere Ressourcen referenziert werden.
Beispiele
{ "resourceType": "Composition", "id": "composition-blutdruck", "meta": { "profile": [ "https://gematik.de/fhir/isik/v3/Basismodul/StructureDefinition/ISiKBerichtSubSysteme" ] }, "status": "final", "text": { "status": "extensions", --- We have skipped the narrative for better readability of the resource --- }, "identifier": { "type": { "coding": [ { "code": "FILL", "system": "http://terminology.hl7.org/CodeSystem/v2-0203" } ] }, "system": "https://fhir.krankenhaus.example/sid/system-a/berichtnummer", "value": "0123456789" }, "type": { "coding": [ { "code": "55112-7", "system": "http://loinc.org" } ] }, "subject": { "reference": "urn:uuid:3bada18a-6fd2-11ed-a1eb-0242ac112345" }, "encounter": { "reference": "urn:uuid:74b46c1a-6fc9-11ed-a1eb-0242ac198765" }, "date": "2022-05-03", "author": [ { "type": "Device", "display": "Gerät XY, Fa. Z, Modell T" } ], "title": "Blutdruckmessung vom 3.5.2022", "section": [ { "title": "Messung", "text": { "status": "generated", "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\"><table><tr><td><b>Systolisch</b></td><td><b>Diastolisch</b></td><td><b>Einheit</b></td><td><b>Uhrzeit</b></td></tr><tr><td>140</td><td>110</td><td>mmHG</td><td>17:15h</td></tr></table></div>" } } ] }