Generated Narrative: StructureDefinition ISiKDokumentenMetadaten Name Flags Card. Type Description & Constraints DocumentReference 0..* DocumentReference A reference to a document #xD; id S 0..1 id serverseitige, interne ID des Datensatzes #xD; meta #xD; versionId 0..1 id Eindeutiger Name der serverseitigen Version des Datensatzes #xD; lastUpdated 0..1 instant Zeitpunkt der letzten Änderung #xD; masterIdentifier S 1..1 Identifier Versionsspezifische OID des Dokumentes #xD; system S 1..1 uri Namensraum des Identifiers #xD; value S 1..1 string Wert des Identifiers #xD; identifier S 0..* Identifier Identifier des Dokumentes #xD; status S 1..1 code Status des Dokumentenmetadatensatzes #xD; docStatus S 0..1 code Bearbeitungsstatus des Dokumentes #xD; type S 1..1 CodeableConcept Dokumententyp #xD; Slices for coding 1..* Coding Code defined by a terminology system Slice: Unordered, Open by pattern:$this #xD; coding:KDL S 1..1 Coding Dokumenttyp gem. KDL-Terminologie Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl #xD; system S 1..1 uri Kodiersystem #xD; code S 1..1 code Code #xD; display S 1..1 string Anzeigetext #xD; coding:XDS S 0..1 Coding Dokumenttyp gem. IHE-De-Terminologie Binding: IHE XDS typeCode (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode #xD; system S 1..1 uri Kodiersystem #xD; code S 1..1 code Code #xD; display S 1..1 string Anzeigetext #xD; category S 0..1 CodeableConcept Dokumentklasse/-Kategorie #xD; Slices for coding 1..* Coding Code defined by a terminology system Slice: Unordered, Open by pattern:$this #xD; coding:XDS S 1..1 Coding Code defined by a terminology system Binding: IHE XDS classCode (required) Required Pattern: At least the following #xD; system 1..1 uri Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode #xD; system S 1..1 uri Kodiersystem #xD; code S 1..1 code Code #xD; display S 1..1 string Anzeigetext #xD; subject S 1..1 Reference(Patient | Practitioner | Group | Device) Patientenbezug #xD; reference S 0..1 string Patienten-Link #xD; identifier S 0..1 Identifier Patienten-Link (logische Referenz) #xD; system S 1..1 uri The namespace for the identifier value #xD; value S 1..1 string The value that is unique #xD; date 0..1 instant When this document reference was created #xD; author S 0..* Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson) Autor des Dokumentes #xD; display S 0..1 string Text alternative for the resource #xD; relatesTo S 0..* BackboneElement Beziehung zu anderen Dokumenten #xD; code 1..1 code replaces | transforms | signs | appends #xD; target 1..1 Reference(DocumentReference) Target of the relationship #xD; description 0..1 string Human-readable description #xD; securityLabel S 1..* CodeableConcept Vertraulichkeit Binding: ISiKConfidentialityCodes (required) #xD; content S 1..1 BackboneElement Beschreibung des Dokumenteninhaltes #xD; attachment S 1..1 Attachment Anhang #xD; contentType S 1..1 code Mimetype des Dokumentes #xD; language S 1..1 code Sprache, in der das Dokument verfasst wurde. #xD; data S 0..1 base64Binary Base64-codierte Binärdaten #xD; url S 0..1 url Referenz auf Dokument #xD; title S 1..1 string Bezeichnung des Dokuments #xD; creation S 1..1 dateTime Dokumentendatum #xD; format S 1..1 Coding Format des Dokumentes Binding: IHE XDS formatCode (required) #xD; context S 1..1 BackboneElement Kontextinformationen zum Dokument #xD; encounter S 0..1 Reference(Encounter | EpisodeOfCare) Aufenthaltsbezug #xD; reference S 1..1 string Encounter-Link #xD; event 0..* CodeableConcept Main clinical acts documented Binding: IHE XDS eventCodeList (required) #xD; coding 1..1 Coding Code defined by a terminology system #xD; system 1..1 uri Identity of the terminology system #xD; code 1..1 code Symbol in syntax defined by the system #xD; facilityType S 1..1 CodeableConcept Art der Einrichtung, aus der das Dokument stammt Binding: IHE XDS healthcareFacilityTypeCode (required) #xD; practiceSetting S 1..1 CodeableConcept Additional details about where the content was created (e.g. clinical specialty) Binding: IHE XDS practiceSettingCode (required) #xD; Documentation for this format
Erforderliche Metadaten für Dokumentenaustausch in ISiK
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](https://profiles.ihe.net/ITI/MHD/StructureDefinition-IHE.MHD.UnContained.Comprehensive.DocumentReference.html) (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](https://simplifier.net/kdl/%7Eresources?category=ConceptMap&sortBy=RankScore_desc) 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.
Metadaten eines strukturieren Dokumentes (Document-Bundle)
A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.
Usually, this is used for documents other than those defined by FHIR.
If the resource is contained in another resource, it SHALL NOT contain nested Resources
not(parent::f:contained and f:contained)
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()
not(exists(for $id in f:contained/*/f:id/@value return $contained[not(parent::*/descendant::f:reference/@value=concat('#', $contained/*/id/@value) or descendant::f:reference[@value='#'])]))
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()
not(exists(f:contained/*/f:meta/f:versionId)) and not(exists(f:contained/*/f:meta/f:lastUpdated))
If a resource is contained in another resource, it SHALL NOT have a security label
When a resource has no narrative, only systems that fully understand the data can display the resource to a human safely. Including a human readable representation in the resource makes for a much more robust eco-system and cheaper handling of resources by intermediary systems. Some ecosystems restrict distribution of resources to only those systems that do fully understand the resources, and as a consequence implementers may believe that the narrative is superfluous. However experience shows that such eco-systems often open up to new participants over time.
A resource should have narrative for robust management
Document[classCode="DOC" and moodCode="EVN"]
serverseitige, interne ID des Datensatzes
The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.
**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 `id`verfügen.
The 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.
All FHIR elements must have a @value or children
hasValue() or (children().count() > id.count())
Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
Extensions are always sliced by (at least) url
Additional content defined by implementations
May 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.
Must have either extensions or value[x], not both
exists(f:extension)!=exists(f:*[starts-with(local-name(.), "value")])
Eindeutiger Name der serverseitigen Version des Datensatzes
The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.
Alle von einem Server bereitgestellten Ressourcen SOLLEN über eine `versionID` verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über eine `versionID`verfügen.
When the resource last changed - e.g. when the version changed.
Alle von einem Server bereitgestellten Ressourcen SOLLEN über ein `lastUpdate` verfügen. Von Clients erzeugte Ressourcen, die im Kontext einer CREATE-Interaktion übermittelt werden, MÜSSEN NICHT über ein `lastUpdate`verfügen.
Identifies where the resource comes from
A uri that identifies the source system of the resource. This provides a minimal amount of [Provenance](http://hl7.org/fhir/R4/provenance.html#) information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.
In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used. This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.
Profiles this resource claims to conform to
A list of profiles (references to [StructureDefinition](http://hl7.org/fhir/R4/structuredefinition.html#) resources) that this resource claims to conform to. The URL is a reference to [StructureDefinition.url](http://hl7.org/fhir/R4/structuredefinition-definitions.html#StructureDefinition.url).
It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.
Security Labels applied to this resource
Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.
The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.
Security Labels from the Healthcare Privacy and Security Classification System.
Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.
The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.
Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
A set of rules under which this content was created
A 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.
This element is labeled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation
The 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).
Text summary of the resource, for human interpretation
A 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.
These 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.
May 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.
May 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](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).
Modifier extensions are expected to modify the meaning or interpretation of the resource that contains them
Document identifier as assigned by the source of the document. This identifier is specific to this version of the document. This unique identifier may be used elsewhere to identify this version of the document.
**Begründung Must Support:** Die OID ist erforderlich, um die Version des Dokumentes eindeutig zu identifizieren.
The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).
usual | official | temp | secondary | old (If known)
Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.
Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.
This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one.
Identifies the purpose for this identifier, if known .
A coded type for the identifier that can be used to determine which identifier to use for a specific purpose.
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.
Allows users to make use of identifiers when the identifier system is not known.
A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
Establishes the namespace for the value - that is, a URL that describes a set values that are unique.
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](https://profiles.ihe.net/ITI/TF/Volume2/ch-Z.html#z.9-fhir-data-types) zu finden.
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.
The portion of the identifier typically relevant to the user and which is unique within the context of the system.
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](https://wiki.ihe.net/index.php/Creating_Unique_IDs_-_OID_and_UUID).
II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
Time period when id is/was valid for use
Time period during which identifier is/was valid for use.
Role.effectiveTime or implied by context
Organization that issued id (may be just text)
Organization 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.
II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
Other identifiers associated with the document, including version independent identifiers.
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.
Der Status des Dokumentes wird in DocumentReference.docStatus gesetzt.
This element is labelled as a modifier because it is a status element that contains status entered-in-error which means that the resource should not be treated as valid
interim: .completionCode="IN" & ./statusCode[isNormalDatatype()]="active"; final: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and not(./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct()]); amended: .completionCode="AU" && ./statusCode[isNormalDatatype()]="complete" and ./inboundRelationship[typeCode="SUBJ" and isNormalActRelationship()]/source[subsumesCode("ActClass#CACT") and moodCode="EVN" and domainMember("ReviseDocument", code) and isNormalAct() and statusCode="completed"]; withdrawn : .completionCode=NI && ./statusCode[isNormalDatatype()]="obsolete"
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]
Specifies the particular kind of document referenced (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the document referenced.
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](https://simplifier.net/kdl/~resources?category=ConceptMap) 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.
ClinicalDocument/code/@code The typeCode should be mapped from the ClinicalDocument/code element to a set of document type codes configured in the affinity domain. One suggested coding system to use for typeCode is LOINC, in which case the mapping step can be omitted.
A reference to a code defined by a terminology system.
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.
Allows for alternative encodings within a code system, and translations to other code systems.
fhir:CodeableConcept.coding rdfs:subPropertyOf dt:CD.coding
The identification of the code system that defines the meaning of the symbol in the code.
Fix: "http://dvmd.de/fhir/CodeSystem/kdl"
Need to be unambiguous about the source of the definition of the symbol.
fhir:Coding.system rdfs:subPropertyOf dt:CDCoding.codeSystem
The 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.
fhir:Coding.version rdfs:subPropertyOf dt:CDCoding.codeSystemVersion
A 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.
fhir:Coding.code rdfs:subPropertyOf dt:CDCoding.code
A 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.
C*E.2 - but note this is not well followed
fhir:Coding.display rdfs:subPropertyOf dt:CDCoding.displayName
If this coding was chosen directly by the user
Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).
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.
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.
fhir:Coding.userSelected fhir:mapsTo dt:CDCoding.codingRationale. fhir:Coding.userSelected fhir:hasMap fhir:Coding.userSelected.map. fhir:Coding.userSelected.map a fhir:Map; fhir:target dt:CDCoding.codingRationale. fhir:Coding.userSelected\#true a [ fhir:source "true"; fhir:target dt:CDCoding.codingRationale\#O ]
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](https://simplifier.net/kdl) publizierten [ConceptMaps](https://simplifier.net/kdl/~resources?category=ConceptMap) aus dem KDL-Code ermittelt werden
Kann mittels Lookup in den KDL->XDS ConceptMaps anhand des KDL-Type-Codes ermittelt werden
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.
Plain text representation of the concept
A 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.
Very often the text is the same as a displayName of one of the codings.
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.
C*E.9. But note many systems use C*E.2 for this
fhir:CodeableConcept.text rdfs:subPropertyOf dt:CD.originalText
A categorization for the type of document referenced - helps for indexing and searching. This may be implied by or derived from the code specified in the DocumentReference.type.
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](https://simplifier.net/kdl/~resources?category=ConceptMap) aus dem KDL-Code ermittelt werden.
High-level kind of a clinical document at a macro level.
.outboundRelationship[typeCode="COMP].target[classCode="LIST", moodCode="EVN"].code
Derived from a mapping of /ClinicalDocument/code/@code to an Affinity Domain specified coded value to use and coding system. Affinity Domains are encouraged to use the appropriate value for Type of Service, based on the LOINC Type of Service (see Page 53 of the LOINC User's Manual). Must be consistent with /ClinicalDocument/code/@code
Who or what the document is about. The document 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 farm animals, or a set of patients that share a common exposure).
**Begründung Must-Support:** Ein Patientenbezug der Prozedur MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Lookup Composition.subject.resolve().identifier[PID]
Ermittlung des korrekten Patienten auf dem Server anhand des Identifiers (PID) und/oder weiterer Kriterien erforderlich
PID-3 (No standard way to define a Practitioner or Group subject in HL7 v2 MDM message)
A 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.
**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](https://gematik.de/fhir/isik/StructureDefinition/ISiKPatient) sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Type the reference refers to (e.g. "Patient")
The 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).
An 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.
**Bedingtes Must Support:** Logische Referenzen KÖNNEN als Alternative zur Verlinkung über `reference`genutzt werden. BITTE HINWEISE BEACHTEN: {{pagelink:Dokumentenbereitstellung text:Interaktion:Dokumentenbereitstellung > Herstellung von Patienten- und Encounterkontext > Option 5}}
Identifier.system is always case sensitive.
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](http://hl7.org/fhir/R4/extension-rendered-value.html). 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.
Plain 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.
When this document reference was created
When the document reference was created.
Abweichend zu MHD V4.0.1 ist die Verwendung von date im ISiK-Kontext nicht verpflichtend. Die Motivation für die verbindliche Verwendung von `date` seitens IHE ist nicht nachvollziehbar. Ein entsprechender Change Request zur Harmonisierung wurde eingereicht. Das Dokumentendatum wird in attachment.creation gesetzt. Update für Stufe 3: In MHD 4.2.0 wurde die Verpflichtung zur Angabe von date gelockert, das ISiK-Profil ist damit in diesem Punkt wieder kompatibel zu IHE MHD.
Identifies who is responsible for adding the information to the document.
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.
TXA-9 (No standard way to indicate a Device in HL7 v2 MDM message)
Literal reference, Relative, internal or absolute URL
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.
Logical reference, when literal reference is not known
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).
Which person or organization authenticates that this document is valid.
Represents a participant within the author institution who has legally authenticated or attested the document. Legal authentication implies that a document has been signed manually or electronically by the legal Authenticator.
Organization which maintains the document
Identifies the organization or group who is responsible for ongoing maintenance of and access to the document.
Identifies the logical organization (software system, vendor, or department) to go to find the current version, where to report issues, etc. This is different from the physical location (URL, disk drive, or server) of the document, which is the technical location of the document, which host may be delegated to the management of some other organization.
.participation[typeCode="RCV"].role[classCode="CUST"].scoper[classCode="ORG" and determinerCode="INST"]
Relationships that this document has with other document references that already exist.
Inbesondere relevant im Kontext von Updates. Bei inhaltlichen Updates MUSS eine `replaces`-Relation angegeben werden.
Extensions that cannot be ignored even if unrecognized
May 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 are expected to modify the meaning or interpretation of the element that contains them
The type of relationship that this document has with anther 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.
The target document of this relationship.
Lookup Composition.relatesTo.targetReference.resolve().identifier
Ermittlung der zu ersetzenden DocumentReference anhand des identifiers der referenzierten Composition erforderlich
.target[classCode="DOC", moodCode="EVN"].id
Human-readable description of the source document.
Optionaler Freitext zur ergänzenden Beschreibung des Dokumentes. Die eigentliche menschenlesbare Bezeichnung des Dokuments zur Anzeige in Benutzeroberflächen sollte in 'content.attachment.title' angegeben werden. 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. Das Element 'description' kann weiterhin verwendet werden, um inhaltliche Hinweise zum Dokument, eine knappe Zusammenfassung oder ergänzende Kommentare bereitzustellen.
Helps humans to assess whether the document is of interest.
A set of Security-Tag codes specifying the level of privacy/security of the Document. Note that DocumentReference.meta.security contains the security labels of the "reference" to the document, while DocumentReference.securityLabel contains a snapshot of the security labels on the document the reference refers to.
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]
Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.
Composition.confidentiality, Composition.meta.security
The document and format referenced. There may be multiple content element repetitions, each with a different format.
Die Kardinalität wurde angepasst, um den Vorgaben von IHE MHD zu ensprechen [Änderung im Zuge der Kommentierung Stufe 3].
The document or URL of the document along with critical metadata to prove content has integrity.
Composition.language, Composition.title, Composition.date
DocumentEntry.mimeType, DocumentEntry.languageCode, DocumentEntry.URI, DocumentEntry.size, DocumentEntry.hash, DocumentEntry.title, DocumentEntry.creationTime
ClinicalDocument/languageCode, ClinicalDocument/title, ClinicalDocument/date
Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.
Mimetype (Dateityp) des Dokumentes (z.B. "application/pdf")
Processors of the data need to be able to know how to interpret the data.
The mime type of an attachment. Any valid mime type is allowed.
`application/html` für den extrahierten Narrative, `application/fhir+xml` oder `application/fhir+json` für das Bundle
ED.2+ED.3/RP.2+RP.3. Note conversion may be needed if old style values are being used
Sprache, in der das Dokument verfasst wurde.
The human language of the content. The value can be any valid value according to BCP 47.
Kann bei Systemen, die keine Mehrsprachigkeit unterstützen, fest auf "de" oder "de-DE" gesetzt werden.
Users need to be able to choose between the languages in a set of attachments.
=de sofern keine abweichende Angabe in Composition.language
The actual data of the attachment - a sequence of bytes, base64 encoded.
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.
The data needs to able to be transmitted inline.
A location where the data can be accessed.
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](https://gematik.de/fhir/isik/v3/Basismodul/StructureDefinition/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.
The data needs to be transmitted by reference.
vom Server festgelegter Speicherort des Bundles/Narratives
RP.1+RP.2 - if they refer to a URL (see v2.6)
Number of bytes of content (if url provided)
The number of bytes of data that make up this attachment (before base64 encoding, if that is done).
The number of bytes is redundant if the data is provided as a base64binary, but is useful if the data is provided as a url reference.
Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.
The calculated hash of the data using SHA-1. Represented using base64.
The hash is calculated on the data prior to base64 encoding, if the data is based64 encoded. The hash is not intended to support digital signatures. Where protection against malicious threats a digital signature should be considered, see [Provenance.signature](http://hl7.org/fhir/R4/provenance-definitions.html#Provenance.signature) for mechanism to protect a resource with a digital signature.
Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).
A label or set of text to display in place of the data.
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.
Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.
The date that the attachment was first created.
Es obliegt dem erzeugenden System, zu entscheiden, welches Datum als Dokumentendatum geeignet ist, z.B. Datum der Erstellung oder Datum der letzten Änderung
This is often tracked as an integrity issue for use of the attachment.
An identifier of the document encoding, structure, and template that the document conforms to beyond the base format indicated in the mimeType.
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"
derived from the IHE Profile or Implementation Guide templateID
The clinical context in which the document was prepared.
**Begründung Must Support:** Kontextinformationen sind erforderlich, um die Relevanz und den Bezug des Dokuments zu verstehen.
Describes the clinical encounter or type of care that the document content is associated with.
**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.
Lookup Composition.encounter.resolve().identifier
Ermittlung des korrekten Encounters auf dem Server anhand des Identifiers(Fallnummer) und/oder weiterer Kriterien erforderlich
unique(highest(./outboundRelationship[typeCode="SUBJ" and isNormalActRelationship()], priorityNumber)/target[moodCode="EVN" and classCode=("ENC", "PCPR") and isNormalAct])
**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](https://gematik.de/fhir/isik/StructureDefinition/ISiKKontaktGesundheitseinrichtung) sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
This 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 type Code, such as a "History and Physical Report" in which the procedure being documented is necessarily a "History and Physical" act.
Binding auf IHE-DE Terminologie hinzugefügt
Time of service that is being documented
The time period over which the service that is described by the document was provided.
DocumentEntry.serviceStartTime, DocumentEntry.serviceStopTime
ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/low/ @value --> ClinicalDocument/documentationOf/ serviceEvent/effectiveTime/high/ @value
Art der Einrichtung, aus der das Dokument stammt
The kind of facility where the patient was seen.
Kann, sofern keine abweichende Information bekannt ist auf "KHS" gesetzt werden.
usually from a mapping to a local ValueSet
usually a mapping to a local ValueSet. Must be consistent with /clinicalDocument/code
Additional details about where the content was created (e.g. clinical specialty)
This property may convey specifics about the practice setting where the content was created, often reflecting the clinical specialty.
This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.
Lookup Composition.encounter.resolve().serviceType
Mapping per https://wiki.hl7.de/index.php?title=Ihevs:DocumentEntry.PracticeSettingCode von Fachabteilungsschlüssel auf PracticeSetting erforderlich.
The Patient Information as known when the document was published. May be a reference to a version specific, or contained.
DocumentEntry.sourcePatientInfo, DocumentEntry.sourcePatientId
Related identifiers or resources associated with the DocumentReference.
May be identifiers or resources that caused the DocumentReference or referenced Document to be created.
./outboundRelationship[typeCode="PERT" and isNormalActRelationship()] / target[isNormalAct]