ISiK Dokumentenaustausch Implementierungsleitfaden
Version 6.0.0-rc - ci-build

Resource Profile: Erforderliche Metadaten für Dokumentenaustausch in ISiK

Official URL: https://gematik.de/fhir/isik/StructureDefinition/ISiKDokumentenMetadaten Version: 6.0.0-rc
Active as of 2025-12-17 Computable Name: ISiKDokumentenMetadaten

Dieses Profil spezifiziert die Minimalanforderungen für die Bereitstellung von Dokumentenmetadaten im Rahmen des Bestätigungsverfahrens der gematik.

### Motivation Die Ressource DocumentReference enthält die Metadaten, die für die Verwaltung von und die Suche nach Dokumenten benötigt werden. Der Inhalt des Dokumentes wird über DocumentReference.content beschrieben und über DocumentReference.content.attachment referenziert. Die Trennung von Dokument und Metadaten ermöglicht Clients die effiziente Suche und Auflistung von verfügbaren Dokumenten, ohne dass diese vollständig vom Server geladen werden müssen. Servern ermöglicht dieser Ansatz die Trennung zwischen den Metadaten in einer Datenbank und der Dokumentenablage in z.B. einem Dateisystem.

### Kompatibilität Dieses Profil basiert auf dem Profil MHD DocumentReference Comprehensive UnContained References Option (Version 4.2.0) von IHE International.

#### Abweichungen vom IHE-Profil

  • Die Verwendung von DocumentReference.docStatus ist im ISiK-Kontext gestattet.
  • DocumentReference.category muss vom Client bei Vorhandensein eines KDL-Codes in DocumentReference.type nicht gefüllt werden. Bei der Verarbeitung auf dem Server im Rahmen der Interaktion {{pagelink: Dokumentenbereitstellung}} wird DocumentReference.category anhand der KDL-Mappings ergänzt und damit die IHE-Kompatibilität hergestellt.
  • DocumentReference.sourcePatientInfo muss im Rahmen von ISiK nicht gefüllt werden

Einschränkungen des IHE-Profils

Elemente mit ValueSet-Bindings ohne verbindliche Vorgabe seitens IHE wurden auf die in Deutschland gebräuchlichen Terminologien (gemäß der Festlegungen von IHE Deutschland e.V.) eingeschränkt.

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... system SΣ 1..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Wert des Identifiers
Example General: 123456
... identifier SΣ 0..* Identifier Identifier des Dokumentes
... status ?!SΣ 1..1 code Status des Dokumentenmetadatensatzes
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus SΣ 0..1 code Bearbeitungsstatus des Dokumentes
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Dokumententyp
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
..... coding:XDS SΣ 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
... category SΣ 0..1 CodeableConcept Dokumentklasse/-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS SΣ 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
... subject SΣ 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... reference SΣC 0..1 string Patienten-Link
.... identifier SΣ 0..1 Identifier Patienten-Link (logische Referenz)
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... display SΣ 0..1 string Text alternative for the resource
... relatesTo SΣ 0..* BackboneElement Beziehung zu anderen Dokumenten
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content SΣ 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Anhang
..... contentType SΣ 1..1 code Mimetype des Dokumentes
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument verfasst wurde.
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url SΣ 0..1 url Referenz auf Dokument
Example General: http://www.acme.com/logo-small.png
..... title SΣ 1..1 string Bezeichnung des Dokuments
Example General: Official Corporate Logo
..... creation SΣ 1..1 dateTime Dokumentendatum
.... format SΣ 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context SΣ 1..1 BackboneElement Kontextinformationen zum Dokument
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... reference SΣC 1..1 string Encounter-Link
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... coding Σ 1..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.masterIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.subject.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DocumentReference If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DocumentReference If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DocumentReference A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... masterIdentifier S 1..1 Identifier Versionsspezifische OID des Dokumentes
.... system S 1..1 uri Namensraum des Identifiers
.... value S 1..1 string Wert des Identifiers
... status S 1..1 code Status des Dokumentenmetadatensatzes
... docStatus S 0..1 code Bearbeitungsstatus des Dokumentes
... type S 1..1 CodeableConcept Dokumententyp
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL S 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
..... coding:XDS S 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
... category S 0..1 CodeableConcept Dokumentklasse/-Kategorie
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS S 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
... subject S 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... reference S 0..1 string Patienten-Link
.... identifier S 0..1 Identifier Patienten-Link (logische Referenz)
..... system S 1..1 uri The namespace for the identifier value
..... value S 1..1 string The value that is unique
... date 0..1 instant When this document reference was created
... author S 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... display S 0..1 string Text alternative for the resource
... relatesTo S 0..* BackboneElement Beziehung zu anderen Dokumenten
.... code 1..1 code replaces | transforms | signs | appends
.... target 1..1 Reference(DocumentReference) Target of the relationship
... description 0..1 string Human-readable description
... securityLabel S 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content S 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... attachment S 1..1 Attachment Anhang
..... contentType S 1..1 code Mimetype des Dokumentes
..... language S 1..1 code Sprache, in der das Dokument verfasst wurde.
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url S 0..1 url Referenz auf Dokument
..... title S 1..1 string Bezeichnung des Dokuments
..... creation S 1..1 dateTime Dokumentendatum
.... format S 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context S 1..1 BackboneElement Kontextinformationen zum Dokument
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... reference S 1..1 string Encounter-Link
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... coding 1..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Versionsspezifische OID des Dokumentes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system SΣ 1..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Wert des Identifiers
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... identifier SΣ 0..* Identifier Identifier des Dokumentes
... status ?!SΣ 1..1 code Status des Dokumentenmetadatensatzes
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus SΣ 0..1 code Bearbeitungsstatus des Dokumentes
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Dokumententyp
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:XDS SΣ 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... category SΣ 0..1 CodeableConcept Dokumentklasse/-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS SΣ 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier SΣ 0..1 Identifier Patienten-Link (logische Referenz)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display SΣ 0..1 string Text alternative for the resource
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
... custodian 0..1 Reference(Organization) Organization which maintains the document
... relatesTo SΣ 0..* BackboneElement Beziehung zu anderen Dokumenten
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content SΣ 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Anhang
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code Mimetype des Dokumentes
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument verfasst wurde.
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url SΣ 0..1 url Referenz auf Dokument
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 1..1 string Bezeichnung des Dokuments
Example General: Official Corporate Logo
..... creation SΣ 1..1 dateTime Dokumentendatum
.... format SΣ 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context SΣ 1..1 BackboneElement Kontextinformationen zum Dokument
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 1..1 string Encounter-Link
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 1..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... period Σ 0..1 Period Time of service that is being documented
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.masterIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.masterIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.subject.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.subject.​identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.author.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​encounter.type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DocumentReference If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DocumentReference If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DocumentReference A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()
ElementShort descriptionNotes
DocumentReference.author Autor des Dokumentes

In dieser Ausbaustufe ist die Nennung des Namens oder Kürzels des Autors ausreichend. Eine darüber hinaus gehende Verlinkung auf einen Practitioner (auflösbar auf dem Server) ist möglich aber nicht erforderlich.
DocumentReference.author.display
DocumentReference.category Dokumentklasse/-Kategorie

Die Kategorisierung von Dokumenten erfolgt mittels der von IHE Deutschland publizierten XDS-Class-Codes. Die übermittlung des XDS-Class-Codes ist im Rahmen der Dokumentenbereitstellung für Clients nicht verpflichtend, muss jedoch vom Server bei der Entgegennahme ggf. ergänzt und bei der Dokumentenabfrage zurückgegeben werden. Der XDS-Class-Code kann mit Hilfe der bereitgestellten ConceptMap aus dem KDL-Code ermittelt werden.
DocumentReference.category.coding:XDS
DocumentReference.category.coding:XDS.code Code

Der XDS-Class-Code
DocumentReference.category.coding:XDS.display Anzeigetext

Der Anzeigetext zum XDS-Class-Code
DocumentReference.category.coding:XDS.system Kodiersystem
DocumentReference.content Beschreibung des Dokumenteninhaltes

Die Kardinalität wurde angepasst, um den Vorgaben von IHE MHD zu ensprechen [Änderung im Zuge der Kommentierung Stufe 3].
DocumentReference.content.attachment Anhang
DocumentReference.content.attachment.contentType Mimetype des Dokumentes

Mimetype (Dateityp) des Dokumentes (z.B. "application/pdf")
DocumentReference.content.attachment.creation Dokumentendatum

Es obliegt dem erzeugenden System, zu entscheiden, welches Datum als Dokumentendatum geeignet ist, z.B. Datum der Erstellung oder Datum der letzten Änderung
DocumentReference.content.attachment.data Base64-codierte Binärdaten

Um die Suche nach Dokumenten effizient zu gestalten, dürfen die Dokumente selbst nicht in die DocumentReference eingebettet werden, sondern müssen als separates Datenobjekt referenziert werden.

Update für Stufe 3: Die Ausnahme bildet die Interaktion "Dokumentenbereitstellung", bei der die Binärdaten des Dokumentes eingebettet in die DocumentReference an den Server übermittelt und dort dann in eine separate Ressource ausgelagert und über Attachment.url referenziert werden.

Es ist zu beachten, dass diese base64-codierten Daten wiederum ein FHIR-Bundle (z.B. ein MIO oder ein ISiK Bericht aus einem Subsystem) repräsentieren können. Um eine einheitliche Handhabung der Dokumente für Clients zu ermöglichen werden diese trotz strukturiertem Inhalt per base64 abgebildet.
DocumentReference.content.attachment.language Sprache, in der das Dokument verfasst wurde.

Kann bei Systemen, die keine Mehrsprachigkeit unterstützen, fest auf "de" oder "de-DE" gesetzt werden.
DocumentReference.content.attachment.title Bezeichnung des Dokuments

Menschenlesbare Bezeichnung des Dokuments zur Anzeige in Benutzeroberflächen, z.B. als Titel in einer Dokumentenliste (‘Lungenfunktionstest vom 18.02.2022’).

Update für Stufe 5: Ab dieser Stufe ist für die menschenlesbare Bezeichnung des Dokuments das Element content.attachment.title zu verwenden. Die bisherige Nutzung von DocumentReference.description entfällt zugunsten einer besseren Angleichung an MHD und die ePA-Spezifikation. Implementierungen sollten daher den Titel des Dokuments ausschließlich in content.attachment.title angeben.
DocumentReference.content.attachment.url Referenz auf Dokument

Um die Suche nach Dokumenten effizient zu gestalten, dürfen die Dokumente selbst nicht in die DocumentReference eingebettet werden, sondern müssen als separates Datenobjekt referenziert werden.

​Wird ein separates Datenobjekt im ISIK-Kontext referenziert, so MUSS dieses konform zum Profil ISIKBinary aus dem Basismodul sein.

Update für Stufe 3: Die Ausnahme bildet die Interaktion "Dokumentenbereitstellung", bei der die Binärdaten des Dokumentes eingebettet in die DocumentReference an den Server übermittelt und dort dann in eine separate Ressource ausgelagert und über Attachment.url referenziert werden.
DocumentReference.content.format Format des Dokumentes

Sofern das Dokument nicht auf einem standardisierten, strukturierten Austauschformat (z.B. CDA) basiert, für dessen Interpretation ein konkretes Schema herangezogen werden muss, genügt die Angabe des Codes "urn:ihe:iti:xds:2017:mimeTypeSufficient"
DocumentReference.context Kontextinformationen zum Dokument

Begründung Must Support: Kontextinformationen sind erforderlich, um die Relevanz und den Bezug des Dokuments zu verstehen.
DocumentReference.context.encounter Aufenthaltsbezug

Hinweis Kompatibilität: In MHD 4.2.0 wurde das Verbot der Angabe einer Encounter-Referenz gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.
DocumentReference.context.encounter.reference Encounter-Link

​Begründung Pflichtfeld: Die Verlinkung auf eine Encounter-Ressource dient der technischen Zuordnung der Dokumentation zu einem Aufenthalt und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKKontaktGesundheitseinrichtung sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
DocumentReference.context.facilityType Art der Einrichtung, aus der das Dokument stammt

Kann, sofern keine abweichende Information bekannt ist auf "KHS" gesetzt werden.
DocumentReference.context.practiceSetting

Binding auf IHE-DE Terminologie hinzugefügt
DocumentReference.docStatus Bearbeitungsstatus des Dokumentes

Abweichend zu MHD V4.0.1 ist die Verwendung von docStatus im ISiK-Kontext erlaubt. Die Verwendung von docStatus bleibt jedoch optional, da nicht alle Dokumentenerzeugende Systeme einen expliziten Freigabe-Workflow haben. Dokumentenserver müssen jedoch in der Lage sein, den Dokumentenstatus (sofern vorhanden) zu persistieren, anzuzeigen und zu reproduzieren. [Konsens der Arbeitsgruppe vom 10.12.2021]
DocumentReference.id serverseitige, interne ID des Datensatzes

bedingtes Pflichtfeld/bedingtes MS: Alle von einem Server bereitgestellten Ressourcen MÜSSEN über eine id verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine idverfügen.
DocumentReference.identifier Identifier des Dokumentes

Abweichend zu MHD V4.0.1 ist die Angabe eines Identifiers in ISiK nicht erforderlich. Ein solcher kann bei Bedarf (z.B. zur Weitergabe des Dokumentes per XDS) erzeugt werden. [Konsens der Arbeitsgruppe vom 12.11.2021]

Update für Stufe 3: In MHD 4.2.0 wurde die Verpflichtung zur Angabe eines Identifiers gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.
DocumentReference.masterIdentifier Versionsspezifische OID des Dokumentes

Begründung Must Support: Die OID ist erforderlich, um die Version des Dokumentes eindeutig zu identifizieren.
DocumentReference.masterIdentifier.system Namensraum des Identifiers

Bei OIDs und UUIDs ist hier stets der Wert urn:ietf:rfc:3986 anzugeben. Weitere Hinweise zur AbbildungVerwendung von MasterIdentifiern und deren Abbildung auf FHIR sind in IHE-ITI zu finden.
DocumentReference.masterIdentifier.value Wert des Identifiers

OID mit URI-Präfix "urn:oid:". Es sei darauf hingewiesen, dass OIDs auf Basis von UUIDs generiert werden können, ohne einen eigenen Namesraum zu beantragen. Zunächst müssen hierzu alle 128 Bit der UUID in einen Integer-Wert umgerechnet werden. Das Ergebnis muss ohne Bindestriche an die Root-OID ‘2.25’ angehängt werden. Siehe IHE International - Creating Unique IDs - OID and UUID.
DocumentReference.relatesTo Beziehung zu anderen Dokumenten

Inbesondere relevant im Kontext von Updates. Bei inhaltlichen Updates MUSS eine replaces-Relation angegeben werden.
DocumentReference.securityLabel Vertraulichkeit

Die Bereitstellung der Vertraulichkeitsinformation durch den Ersteller des Dokumentes ist verpflichtend. Ebenso sind Dokumentenserver verpflichtet, diese Information zu persistieren und bei der Dokumentenabfrage zu reproduzieren. Die ISiK-Spezifikation trifft jedoch keine Annahmen darüber, wie sich einzelne Vertraulichkeitsstufen auf die Zugriffsberechtigungen verschiedener benutzer auf ein Dokument auswirken. Im ISiK-Kontext ist die Angabe einer der drei Vertraulichkeitsstufen N | R | V verpflichtend, jedoch ohne Einschränkung der Verwendung zusätzlicher Vertraulichkeits-Flags.

[Konsens der Arbeitsgruppe vom 12.11.2021]
DocumentReference.status Status des Dokumentenmetadatensatzes

Der Status des Dokumentes wird in DocumentReference.docStatus gesetzt.
DocumentReference.subject Patientenbezug

Begründung Must-Support: Ein Patientenbezug der Prozedur MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
DocumentReference.subject.identifier Patienten-Link (logische Referenz)

Bedingtes Must Support: Logische Referenzen KÖNNEN als Alternative zur Verlinkung über referencegenutzt werden. BITTE HINWEISE BEACHTEN: {{pagelink:Dokumentenbereitstellung text:Interaktion:Dokumentenbereitstellung > Herstellung von Patienten- und Encounterkontext > Option 5}}
DocumentReference.subject.identifier.system
DocumentReference.subject.identifier.value
DocumentReference.subject.reference Patienten-Link

Bedingtes Pflichtfeld: Clients und Server sind verpflichtet, Dokumente stets mit einem Bezug zu einem Patienten zu versehen.
Leer bleiben darf dieses Element einzig im Kontext der Dokumentenbereitstellung in Verbindung mit der Patientenzuordnung über logische Referenzen, siehe {{pagelink:Dokumentenbereitstellung text:Interaktion:Dokumentenbereitstellung > Herstellung von Patienten- und Encounterkontext > Option 5}}

​Die Verlinkung auf eine Patienten-Ressource dient der technischen Zuordnung der Dokumentation zu einem Patienten und ermöglicht wichtige API-Funktionen wie verkettete Suche, (Reverse-)Include etc. Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKPatient sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
DocumentReference.type Dokumententyp

Im ISiK-Kontext ist die Typisierung eines Dokumentes mit Hilfe eines KDL-Codes und des IHE-XDS-Type-Codes erforderlich und ein Server MUSS beide Kodierungen bereitstellen - trotz der Kardinalität DocumentReference.type.coding:XDS 0..1 -, jedoch ist der IHE-XDS-Type-Code bei Übermittlung für Clients nicht verpflichtend (s.u. zu XDS). Während KDL-Codes eine feingranulare Dokumentenklassifikation für die gezielte Suche nach medizinischen und Administrativen Dokumenten ermöglichen, sind IHE-XDS-Type-Codes für den einrichtungsübergreifenden Dokumentenaustausch maßgeblich. Der XDS-Type-Code kann mit Hilfe der bereitgestellten ConceptMaps aus dem KDL-Code ermittelt werden. Weitere Typisierungen (z.B. nach SNOMED oder LOINC) sind uneingeschränkt erlaubt. [Konsens der Arbeitsgruppe vom 18.02.2022]. Im Falle, dass der Code ‘UNK’ entsprechend der ConceptMap verwendet werden soll, MUSS das System ‘http://terminology.hl7.org/CodeSystem/v3-NullFlavor’ verwendet werden.
DocumentReference.type.coding:KDL Dokumenttyp gem. KDL-Terminologie
DocumentReference.type.coding:KDL.code Code

Der KDL-Code
DocumentReference.type.coding:KDL.display Anzeigetext

Der Anzeigetext zum KDL-Code
DocumentReference.type.coding:KDL.system Kodiersystem

Fix: "http://dvmd.de/fhir/CodeSystem/kdl"
DocumentReference.type.coding:XDS Dokumenttyp gem. IHE-De-Terminologie

Die Übermittlung des XDS-Type-Codes ist im Rahmen der Dokumentenbereitstellung für Clients nicht verpflichtend, MUSS jedoch vom Server bei der Entgegennahme ggf. ergänzt und bei der Dokumentenabfrage zurückgegeben werden. Der XDS-Type-Code kann über die im Rahmen der KDL-Spezifikation publizierten ConceptMaps aus dem KDL-Code ermittelt werden
DocumentReference.type.coding:XDS.code Code

Der XDS-Type-Code
DocumentReference.type.coding:XDS.display Anzeigetext

Der Anzeigetext zum XDS-Type-Code
DocumentReference.type.coding:XDS.system Kodiersystem

This structure is derived from DocumentReference

Summary

Mandatory: 19 elements(14 nested mandatory elements)
Must-Support: 44 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DocumentReference.type.coding
  • The element 1 is sliced based on the value of DocumentReference.category.coding

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... system SΣ 1..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Wert des Identifiers
Example General: 123456
... identifier SΣ 0..* Identifier Identifier des Dokumentes
... status ?!SΣ 1..1 code Status des Dokumentenmetadatensatzes
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus SΣ 0..1 code Bearbeitungsstatus des Dokumentes
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Dokumententyp
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
..... coding:XDS SΣ 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
... category SΣ 0..1 CodeableConcept Dokumentklasse/-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS SΣ 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 1..1 uri Kodiersystem
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
... subject SΣ 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... reference SΣC 0..1 string Patienten-Link
.... identifier SΣ 0..1 Identifier Patienten-Link (logische Referenz)
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... display SΣ 0..1 string Text alternative for the resource
... relatesTo SΣ 0..* BackboneElement Beziehung zu anderen Dokumenten
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content SΣ 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Anhang
..... contentType SΣ 1..1 code Mimetype des Dokumentes
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument verfasst wurde.
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url SΣ 0..1 url Referenz auf Dokument
Example General: http://www.acme.com/logo-small.png
..... title SΣ 1..1 string Bezeichnung des Dokuments
Example General: Official Corporate Logo
..... creation SΣ 1..1 dateTime Dokumentendatum
.... format SΣ 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context SΣ 1..1 BackboneElement Kontextinformationen zum Dokument
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... reference SΣC 1..1 string Encounter-Link
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... coding Σ 1..1 Coding Code defined by a terminology system
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.masterIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.subject.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DocumentReference If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DocumentReference If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DocumentReference A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

Differential View

This structure is derived from DocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id S 0..1 id serverseitige, interne ID des Datensatzes
... meta
.... versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated 0..1 instant Zeitpunkt der letzten Änderung
... masterIdentifier S 1..1 Identifier Versionsspezifische OID des Dokumentes
.... system S 1..1 uri Namensraum des Identifiers
.... value S 1..1 string Wert des Identifiers
... status S 1..1 code Status des Dokumentenmetadatensatzes
... docStatus S 0..1 code Bearbeitungsstatus des Dokumentes
... type S 1..1 CodeableConcept Dokumententyp
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL S 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
..... coding:XDS S 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
... category S 0..1 CodeableConcept Dokumentklasse/-Kategorie
.... Slices for coding 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS S 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... system S 1..1 uri Kodiersystem
...... code S 1..1 code Code
...... display S 1..1 string Anzeigetext
... subject S 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... reference S 0..1 string Patienten-Link
.... identifier S 0..1 Identifier Patienten-Link (logische Referenz)
..... system S 1..1 uri The namespace for the identifier value
..... value S 1..1 string The value that is unique
... date 0..1 instant When this document reference was created
... author S 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... display S 0..1 string Text alternative for the resource
... relatesTo S 0..* BackboneElement Beziehung zu anderen Dokumenten
.... code 1..1 code replaces | transforms | signs | appends
.... target 1..1 Reference(DocumentReference) Target of the relationship
... description 0..1 string Human-readable description
... securityLabel S 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content S 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... attachment S 1..1 Attachment Anhang
..... contentType S 1..1 code Mimetype des Dokumentes
..... language S 1..1 code Sprache, in der das Dokument verfasst wurde.
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url S 0..1 url Referenz auf Dokument
..... title S 1..1 string Bezeichnung des Dokuments
..... creation S 1..1 dateTime Dokumentendatum
.... format S 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context S 1..1 BackboneElement Kontextinformationen zum Dokument
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... reference S 1..1 string Encounter-Link
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... coding 1..1 Coding Code defined by a terminology system
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference 0..* DocumentReference A reference to a document
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... versionId Σ 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated Σ 0..1 instant Zeitpunkt der letzten Änderung
.... source Σ 0..1 uri Identifies where the resource comes from
.... profile Σ 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
.... security Σ 0..* Coding Security Labels applied to this resource
Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
.... tag Σ 0..* Coding Tags applied to this resource
Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... text 0..1 Narrative Text summary of the resource, for human interpretation
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... masterIdentifier SΣ 1..1 Identifier Versionsspezifische OID des Dokumentes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
.... system SΣ 1..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 1..1 string Wert des Identifiers
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... identifier SΣ 0..* Identifier Identifier des Dokumentes
... status ?!SΣ 1..1 code Status des Dokumentenmetadatensatzes
Binding: DocumentReferenceStatus (required): The status of the document reference.
... docStatus SΣ 0..1 code Bearbeitungsstatus des Dokumentes
Binding: CompositionStatus (required): Status of the underlying document.
... type SΣ 1..1 CodeableConcept Dokumententyp
Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 1..1 Coding Dokumenttyp gem. KDL-Terminologie
Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:XDS SΣ 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie
Binding: IHE XDS typeCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... category SΣ 0..1 CodeableConcept Dokumentklasse/-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding Σ 1..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:XDS SΣ 1..1 Coding Code defined by a terminology system
Binding: IHE XDS classCode (required)

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... version 0..1 string Version of the system - if relevant
...... code 0..1 code Symbol in syntax defined by the system
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system SΣ 1..1 uri Kodiersystem
...... version Σ 0..1 string Version of the system - if relevant
...... code SΣ 1..1 code Code
...... display SΣ 1..1 string Anzeigetext
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
.... text Σ 0..1 string Plain text representation of the concept
... subject SΣ 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 0..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier SΣ 0..1 Identifier Patienten-Link (logische Referenz)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
..... type Σ 0..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... system SΣ 1..1 uri The namespace for the identifier value
Example General: http://www.acme.com/identifiers/patient
..... value SΣ 1..1 string The value that is unique
Example General: 123456
..... period Σ 0..1 Period Time period when id is/was valid for use
..... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
.... display Σ 0..1 string Text alternative for the resource
... date Σ 0..1 instant When this document reference was created
... author SΣ 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display SΣ 0..1 string Text alternative for the resource
... authenticator 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
... custodian 0..1 Reference(Organization) Organization which maintains the document
... relatesTo SΣ 0..* BackboneElement Beziehung zu anderen Dokumenten
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code Σ 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target Σ 1..1 Reference(DocumentReference) Target of the relationship
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* CodeableConcept Vertraulichkeit
Binding: ISiKConfidentialityCodes (required)
... content SΣ 1..1 BackboneElement Beschreibung des Dokumenteninhaltes
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣ 1..1 Attachment Anhang
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... contentType SΣ 1..1 code Mimetype des Dokumentes
Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed.
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument verfasst wurde.
Binding: CommonLanguages (preferred): A human language.
Additional BindingsPurpose
AllLanguages Max Binding

Example General: en-AU
..... data S 0..1 base64Binary Base64-codierte Binärdaten
..... url SΣ 0..1 url Referenz auf Dokument
Example General: http://www.acme.com/logo-small.png
..... size Σ 0..1 unsignedInt Number of bytes of content (if url provided)
..... hash Σ 0..1 base64Binary Hash of the data (sha-1, base64ed)
..... title SΣ 1..1 string Bezeichnung des Dokuments
Example General: Official Corporate Logo
..... creation SΣ 1..1 dateTime Dokumentendatum
.... format SΣ 1..1 Coding Format des Dokumentes
Binding: IHE XDS formatCode (required)
... context SΣ 1..1 BackboneElement Kontextinformationen zum Dokument
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... reference SΣC 1..1 string Encounter-Link
..... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
..... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
.... event 0..* CodeableConcept Main clinical acts documented
Binding: IHE XDS eventCodeList (required)
..... id 0..1 string Unique id for inter-element referencing
..... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ 1..1 Coding Code defined by a terminology system
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
...... system Σ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code Σ 1..1 code Symbol in syntax defined by the system
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... period Σ 0..1 Period Time of service that is being documented
.... facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt
Binding: IHE XDS healthcareFacilityTypeCode (required)
.... practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty)
Binding: IHE XDS practiceSettingCode (required)
.... sourcePatientInfo 0..1 Reference(Patient) Patient demographics from source
.... related 0..* Reference(Resource) Related identifiers or resources

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.meta.​security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
DocumentReference.meta.​tag Base example Common Tags 📍4.0.1 FHIR Std.
DocumentReference.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.masterIdentifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.masterIdentifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.docStatus Base required CompositionStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📍4.0.1 FHIR Std.
DocumentReference.type.​coding:KDL Base required ValueSet Klinische Dokumentenklassen-Liste (Version 2025) 📦2025 dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:XDS Base required IHE XDS typeCode 📦2020-02-07T07:55:58 de.ihe-d.terminology v3.0
DocumentReference.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
DocumentReference.category.​coding:XDS Base required IHE XDS classCode 📦2021-06-25T13:44:47 de.ihe-d.terminology v3.0
DocumentReference.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.subject.​identifier.use Base required IdentifierUse 📍4.0.1 FHIR Std.
DocumentReference.subject.​identifier.type Base extensible IdentifierType 📍4.0.1 FHIR Std.
DocumentReference.author.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base required ISiKConfidentialityCodes 📦6.0.0-rc This IG
DocumentReference.content.​attachment.contentType Base required MimeType 📍4.0.1 FHIR Std.
DocumentReference.content.​attachment.language Base preferred Common Languages 📍4.0.1 FHIR Std.
DocumentReference.content.​format Base required IHE XDS formatCode 📦2018-12-14T17:07:12 de.ihe-d.terminology v3.0
DocumentReference.context.​encounter.type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.context.​event Base required IHE XDS eventCodeList 📦2021-07-06T21:19:41 de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType Base required IHE XDS healthcareFacilityTypeCode 📦2021-07-06T21:23:52 de.ihe-d.terminology v3.0
DocumentReference.context.​practiceSetting Base required IHE XDS practiceSettingCode 📦2019-05-17T13:46:31 de.ihe-d.terminology v3.0

Constraints

Id Grade Path(s) Description Expression
dom-2 error DocumentReference If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error DocumentReference If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5 error DocumentReference If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice DocumentReference A resource should have narrative for robust management text.`div`.exists()
ele-1 error **ALL** elements All FHIR elements must have a @value or children hasValue() or (children().count() > id.count())
ext-1 error **ALL** extensions Must have either extensions or value[x], not both extension.exists() != value.exists()

This structure is derived from DocumentReference

Summary

Mandatory: 19 elements(14 nested mandatory elements)
Must-Support: 44 elements

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of DocumentReference.type.coding
  • The element 1 is sliced based on the value of DocumentReference.category.coding

 

Other representations of profile: CSV, Excel, Schematron