ISiK Basis Implementierungsleitfaden
Version 6.0.0-rc - ci-build

Resource Profile: ISiKBerichtSubSysteme

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

Dieses Profil ermöglicht die krankenhaus-interne Übermittlung eines Berichtes bestehend aus beliebigen strukturierten FHIR-Ressourcen sowie einer textuellen HTML-Repräsentation (Narrative) an einen ISiK-Basis-kompatiblen Server.

Motivation

In der heterogenen Systemlandschaft im Krankenhaus sind eine Vielzahl spezialisierter Subsysteme im Einsatz. Die Ergebnisse aus diesen Subsystemen sind aktuell jedoch häufig nicht in den Primärsystemen des Krankenhauses verfügbar, denn es bestehen folgende Herausforderungen:

Die Daten in Subsystemen sind sehr heterogen und können hochspezialisiert sein. Bei der Nutzung dieser Subsysteme besteht häufig ein Interesse, auf die menschenlesbare Repräsentation der strukturierten Daten einwirken zu können. Künftig ist mit Szenarien zu rechnen, bei denen Befunde aus Subsystemen in eine elektronische Patientenakte übertragen werden sollen. Aktuell werden Befunde, obwohl diese in den Subsystemen in hochstrukturierter Form vorliegen, nur als PDF an das Primärsystem übermittelt. Oft weil kein strukturiertes Format spezifiziert ist, das sowohl versendendes Subsystem als auch empfangendes Primärsystem implementiert haben. Der Umfang, in dem eine Datenübernahme in ein Primärsystem möglich ist, variiert stark zwischen den Systemen oder Installationen, z.B. abhängig davon, ob ein Modul für Vitalparameter installiert ist. Die ISiK-Spezifikation begegnet diesen Herausforderungen, indem sie die Übermittlung von Ergebnissen aus Subsystemen an die Primärsysteme in Form von strukturierten Dokumenten erfordert, die über eine menschenlesbare Repräsentation verfügen. Diese strukturierten Dokumente werden im ISiK-Kontext als Berichte bezeichnet. Dabei sind die strukturierten Inhalte der Berichte harmonisiert mit den verbreiteten Formaten für Primärsysteme.

(Semi-)Strukturierte Dokumente werden in FHIR mit der Composition-Ressource repräsentiert, die die Dokumentenmetadaten sowie die textuelle Repräsentation des Dokumentes enthält. Die Composition referenziert auf beliebige weiter FHIR-Ressourcen, die die strukturierten Komponenten des Dokumentes darstellen.

Für den Transport wird die Composition zusammen mit allen direkt oder indirekt referenzierten Ressourcen in eine Bundle-Ressource vom Typ document aggregiert. Das Document-Bundle trägt alle Eigenschaften eines Dokumentes: Abgeschlossenheit, Unveränderbarkeit, Signierbarkeit.

Es obliegt dem empfangenden System, ob dieses Dokument lediglich in seiner Gesamtheit persistiert wird, oder ob darüber hinaus einzelne Bestandteile (Ressourcen) als strukturierte Daten automatisch oder auf Veranlassung eines Benutzers in die Patientenakte übernommen werden.

In der aktuellen Ausbaustufe von ISiK ist lediglich die Übernahme und Anzeige der Dokument-Metadaten (z.B. Dokumenttyp, Dokumentdatum, Quelle) und der menschenlesbaren HTML-Repräsentation in die Primärsysteme erforderlich.

In weiteren Ausbaustufen von ISiK soll darüber hinaus eine Übernahme der strukturierten Anteile der Dokumente möglich sein, die den ISiK-Spezifikationen entsprechen, z.B. Diagnosen und Prozeduren.

Kompatibilität

Hinweise zu Inkompatibilitäten können über die Portalseite gemeldet werden.

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
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... 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
... text S 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... identifier SΣ 1..1 Identifier Eindeutige Dokumenten-ID
.... 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 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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://loinc.org
...... 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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Resource) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... section SC 1..* BackboneElement Kapitel
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 1..1 string Kapitelbezeichnung
.... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition Composition
... 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
... text S 1..1 Narrative Narrativ
.... status S 1..1 code generated | extensions | additional | empty
Fixed Value: extensions
.... div S 1..1 xhtml Limited xhtml content
.... system S 0..1 uri Namensraum des Identifiers
.... value S 0..1 string The value that is unique
... status S 1..1 code Status des Dokumentes
Fixed Value: final
... type S 1..1 CodeableConcept Dokumenttyp
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
..... coding:KDL S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... code C 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
.... text S 0..1 string Dokumenttyp (Freitext)
... category S 0..* CodeableConcept Dokument-Kategorie
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
..... coding:IHE S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
... subject S 1..1 Reference(Resource) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... date S 1..1 dateTime Dokumentendatum
... author S 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... display S 1..1 string Bezeichnung des Verfassers (Freitext)
... title S 1..1 string Dokumentenbezeichnung
... section S 1..* BackboneElement Kapitel
.... title S 1..1 string Kapitelbezeichnung
.... text S 1..1 Narrative Narrativ
.... section S 0..* Unterkapitel

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... 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 S 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Eindeutige Dokumenten-ID
.... 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 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..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)
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... 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 SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... 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
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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 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 SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-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 SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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://loinc.org
...... 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 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
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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 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
... subject SΣ 1..1 Reference(Resource) 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 1..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 Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 0..1 Reference(Encounter) 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
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... 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 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester 0..* BackboneElement Attests to accuracy of composition
.... 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
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..* BackboneElement Kapitel
Constraints: cmp-1, cmp-2
.... 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
.... title S 1..1 string Kapitelbezeichnung
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
.... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 0..* Reference(Resource) A reference to data that supports this section
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Composition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.author.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.0
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()
ElementShort descriptionNotes
Composition.author Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)

In der aktuellen Ausbaustufe von ISiK ist die Verwendung der textuellen Repräsentation (display) von Autor und Subsystem ausreichend. Die darüber hinausgehende Verlinkung auf Practitioner bzw. Device-Ressourcen KANN implementiert werden.
Composition.author.display Bezeichnung des Verfassers (Freitext)

Freitextliche Bezeichnung des Verfassers (Person oder Subsystem/Gerät)
Composition.category Dokument-Kategorie

Begründung zu Must Support: Die Klassifizierung kann zur Strukturierung der Berichte genutzt werden, in dem Fall, dass das Narrative des Berichts dem Benutzer angezeigt wird. Das Dokument KANN z.B. mittels LOINC oder IHE-D-XDS-Classcodes klassifiziert werden.
Composition.category.coding
Composition.category.coding:IHE
Composition.category.coding:LOINC
Composition.date Dokumentendatum

Datum der letzten Änderung des Dokumentes
Composition.encounter Aufenthaltsbezug

Begründung Must-Support: Ein Aufenthaltsbezug des Dokument MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Composition.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. WICHTIGER Hinweis für Implementierer: Die Zuordnung MUSS auf einen Encounter der Ebene “Abteilungskontakt” (siehe hierzu Basismodul > UseCases > Abbildung des Konstruktes “Fall”) erfolgen.
Bei der Auswahl des Encounters ist zu beachten, dass unter einer (Abrechnungs-)”Fallnummer” (hier: Encounter.account) unter Umständen mehrere Encounter gruppiert sein können (z.B. stationärer Besuch mit mehreren vor- und nachstationären Aufenthalten.) Im ISik Kontext MUSS die referenzierte Ressource konform zu ISiKKontaktGesundheitseinrichtung sein. Jenseits von ISiK KÖNNEN weitere Instanzen mit anderen Profilen referenziert werden.
Composition.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.
Composition.identifier Eindeutige Dokumenten-ID

Eine vom erzeugenden Subsystem vergebene, eindeutige DokumentenID.
Wenn es sich bei dem verwendeten Identifier um eine OID oder UUID handelt, so ist hier der Wert urn:ietf:rfc:3986 anzugeben und in Identifier.value das jeweilige Präfix urn:uuid: bzw. urn:oid: zu verwenden.
Beispiel:

<identifier> 
    <system value="urn:ietf:rfc:3986">  
    <value value="urn:oid:2.16.840.1.113883.6.96"> 
</identifier>
Composition.identifier.system Namensraum des Identifiers

Hier ist stets der eindeutige Name (URL) des Namensraums anzugeben, aus dem der Identifier stammt. Hinweise zur Festlegung der URLs für lokale Namensräume sind in den Deutschen Basisprofilen beschrieben.
Begründung Pflichtfeld: system stellt in Kombination mit value die Eindeutigkeit eines Identifiers sicher.
Composition.identifier.value

Enthält den eigentlichen Wert des Identifiers.
Begründung Pflichtfeld: Ist der Wert nicht bekannt, sollte der gesamte Slice weggelassen werden.
Composition.section Kapitel

Das Dokument kann in mehrere Kapitel und Unterkapitel gegliedert werden.
Composition.section.section Unterkapitel
Composition.section.text Narrativ

menschenlesbare HTML-Repräsentation des Inhalts dieses Kapitels.
Hinweise: Für Aggregation einer vollständigen menschenlesbaren Repräsentation MÜSSEN die Repräsentationen der einzelnen Kapitel an die Repräsentation der Metadaten (Composition.text) angehängt werden. Für die Separierung KÖNNEN einfache <div>-Tags verwendet werden. Es ist zu beachten, dass Kapitel auch Unterkapitel enthalten KÖNNEN (Composition.section.section), die bei der Aggregation entsprechend berücksichtigt werden MÜSSEN.
Die Mindestanforderungen an den Inhalt der menschenlesbaren Repräsentation umfasst folgende Informationen:

  • section.title + Freitext oder
  • section.title + Resource.text der referenzierten Ressource oder
  • section.title + eine aggregierte Repräsentation von Resource.text, wenn in einer Section mehrere Ressourcen referenziert werden (z.B. eine tabellarische Auflistung mehrere Blutdruckmesswerte, Diagnosen oder Allergien).
Composition.section.title Kapitelbezeichnung
Composition.status Status des Dokumentes

Im Kontext diese Moduls ist nur der Austausch finaler Berichte vorgesehen. Ein Mechanismus zur Änderung oder Ersetzung bereits übermittelter Daten ist derzeit nicht spezifiziert. Hier ist stets der Wert final anzugeben.
Composition.subject Patientenbezug

Begründung Must-Support: Ein Patientenbezug des Dokument MUSS stets zum Zwecke der Nachvollziehbarkeit und Datenintegrität vorliegen.
Composition.subject.reference Patienten-Link

Begründung Pflichtfeld: 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.
Composition.text Narrativ

HTML-Repräsentation des Dokumenten-Headers.
Bitte Hinweise unter Document Presentation beachten.
Der DokumentenHeader muss mindestens die folgenden Informationen enthalten:

  • Composition.subject:Patient.name.family
  • Composition.subject:Patient.birthDate
  • Composition.subject:Patient.identifier:pid
  • Composition.status
  • Composition.type.text
  • Composition.date
  • Composition.title
  • Composition.author.display
Composition.text.div
Composition.text.status
Composition.title Dokumentenbezeichnung

Die Dokumentenbezeichnung dient der Darstellung des Dokumentes in einer Übersicht, z.B. in einer Patientenakte, und KANN der schnellen Auffindbarkeit eines gesuchten Dokumentes dienen. Geeignete Bezeichnungen sind zum Beispiel:

  • ‘Kleines Blutbild vom 13.10.2020’
  • ‘Pathologiebefund (Abstrich) vom 13.10.2020’
  • ‘Blutgasmessung vom 13.10.2020 14:14h’
Composition.type Dokumenttyp

Begründung zu Must Support: Der Dokumenttyp ist für die Identifikation des Berichtes und die Zuordnung zu einem Subsystem für die weitere Verarbeitung erforderlich.

Hinweis für Implementierer: Der zu übermittelnde Bericht repräsentiert eine Zusammenfassung der strukturierten Daten aus dem Subsystem. Das Dokument KANN z.B. mittels KDL oder IHE-D-XDS-Typecodes klassifiziert werden.
Es KANN derzeit jedoch auch eine rein textuelle Beschreibung des Dokumenttyps angegeben werden.

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.
Composition.type.coding
Composition.type.coding:KDL
Composition.type.coding:XDS
Composition.type.text Dokumenttyp (Freitext)

Freitextliche Beschreibung oder assoziierter Displaywert der primären Codierung des Dokumenttyps.

This structure is derived from Composition

Summary

Mandatory: 8 elements(7 nested mandatory elements)
Must-Support: 29 elements
Fixed: 2 elements

Slices

This structure defines the following Slices:

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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... 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
... text S 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... identifier SΣ 1..1 Identifier Eindeutige Dokumenten-ID
.... 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 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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://loinc.org
...... 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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... code Σ 1..1 code Symbol in syntax defined by the system
... subject SΣ 1..1 Reference(Resource) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... section SC 1..* BackboneElement Kapitel
Constraints: cmp-1, cmp-2
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... title S 1..1 string Kapitelbezeichnung
.... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

Differential View

This structure is derived from Composition

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition Composition
... 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
... text S 1..1 Narrative Narrativ
.... status S 1..1 code generated | extensions | additional | empty
Fixed Value: extensions
.... div S 1..1 xhtml Limited xhtml content
.... system S 0..1 uri Namensraum des Identifiers
.... value S 0..1 string The value that is unique
... status S 1..1 code Status des Dokumentes
Fixed Value: final
... type S 1..1 CodeableConcept Dokumenttyp
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
..... coding:KDL S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... code C 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
.... text S 0..1 string Dokumenttyp (Freitext)
... category S 0..* CodeableConcept Dokument-Kategorie
.... Slices for coding S 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
..... coding:IHE S 0..1 Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... system 1..1 uri Identity of the terminology system
...... code 1..1 code Symbol in syntax defined by the system
... subject S 1..1 Reference(Resource) Patientenbezug
.... reference S 1..1 string Patienten-Link
... encounter S 0..1 Reference(Encounter) Aufenthaltsbezug
.... reference S 1..1 string Encounter-Link
... date S 1..1 dateTime Dokumentendatum
... author S 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... display S 1..1 string Bezeichnung des Verfassers (Freitext)
... title S 1..1 string Dokumentenbezeichnung
... section S 1..* BackboneElement Kapitel
.... title S 1..1 string Kapitelbezeichnung
.... text S 1..1 Narrative Narrativ
.... section S 0..* Unterkapitel

doco Documentation for this format

Constraints

Id Grade Path(s) Description Expression
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')

Snapshot View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* Composition A set of resources composed into a single coherent clinical statement with clinical attestation
... 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 S 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... contained 0..* Resource Contained, inline Resources
... extension 0..* Extension Additional content defined by implementations
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Eindeutige Dokumenten-ID
.... 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 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..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)
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... 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 SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:All Slices Content/Rules for all slices
...... 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
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system

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 Σ 1..1 uri Identity of the terminology system
...... version Σ 0..1 string Version of the system - if relevant
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
...... display Σ 0..1 string Representation defined by the system
...... userSelected Σ 0..1 boolean If this coding was chosen directly by the user
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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 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 SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-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 SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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://loinc.org
...... 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 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
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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 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
... subject SΣ 1..1 Reference(Resource) 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 1..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 Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 0..1 Reference(Encounter) 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
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)
.... 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 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... confidentiality Σ 0..1 code As defined by affinity domain
Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
... attester 0..* BackboneElement Attests to accuracy of composition
.... 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
.... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... time 0..1 dateTime When the composition was attested
.... party 0..1 Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) Who attested the composition
... custodian Σ 0..1 Reference(Organization) Organization which maintains the composition
... relatesTo 0..* BackboneElement Relationships to other compositions/documents
.... 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 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... target[x] 1..1 Target of the relationship
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
... event Σ 0..* BackboneElement The clinical service(s) being documented
.... 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 0..* CodeableConcept Code(s) that apply to the event being documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period Σ 0..1 Period The period covered by the documentation
.... detail Σ 0..* Reference(Resource) The event(s) being documented
... section SC 1..* BackboneElement Kapitel
Constraints: cmp-1, cmp-2
.... 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
.... title S 1..1 string Kapitelbezeichnung
.... code 0..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
.... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
.... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
.... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... mode 0..1 code working | snapshot | changes
Binding: ListMode (required): The processing mode that applies to this section.
.... orderedBy 0..1 CodeableConcept Order of section entries
Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
.... entry C 0..* Reference(Resource) A reference to data that supports this section
.... emptyReason C 0..1 CodeableConcept Why the section is empty
Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
.... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.meta.security Base extensible SecurityLabels 📍4.0.1 FHIR Std.
Composition.meta.tag Base example Common Tags 📍4.0.1 FHIR Std.
Composition.language Base preferred Common Languages 📍4.0.1 FHIR Std.
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📍4.0.1 FHIR Std.
Composition.status Base required CompositionStatus 📍4.0.1 FHIR Std.
Composition.type Base preferred FHIR Document Type Codes 📍4.0.1 FHIR Std.
Composition.category Base example Document Class Value Set 📍4.0.1 FHIR Std.
Composition.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.encounter.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.author.type Base extensible ResourceType 📍4.0.1 FHIR Std.
Composition.confidentiality Base required V3 Value SetConfidentialityClassification 📍2014-03-26 FHIR Std.
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.event.code Base example v3 Code System ActCode 📦3.0.0 THO v7.0
Composition.section.​code Base example Document Section Codes 📍4.0.1 FHIR Std.
Composition.section.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section.​orderedBy Base preferred List Order Codes 📍4.0.1 FHIR Std.
Composition.section.​emptyReason Base preferred List Empty Reasons 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section A section must contain at least one of text, entries, or sub-sections text.exists() or entry.exists() or section.exists()
cmp-2 error Composition.section A section can only have an emptyReason if it is empty emptyReason.empty() or entry.empty()
dom-2 error Composition If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty()
dom-3 error Composition 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 Composition 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 Composition If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty()
dom-6 best practice Composition 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

This structure is derived from Composition

Summary

Mandatory: 8 elements(7 nested mandatory elements)
Must-Support: 29 elements
Fixed: 2 elements

Slices

This structure defines the following Slices:

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

 

Other representations of profile: CSV, Excel, Schematron