Dokumentenabfrage und -zugriff

Dokumentenabfrage (IHE MHD ITI-67 (Find DocumentReferences))

Dokumente können anhand ihrer Metadaten gesucht werden. Im Rahmen der ISiK-Spezifikation müssen mindestens die im Kapitel Interaktionen mit MUSS gekennzeichneten Suchparameter unterstützt werden. Einzelnen Systemen steht es frei, darüber hinaus weitere FHIR-konforme Suchparameter zu implementieren.

Die Ergebnisse einer Suchanfrage werden in Form eines Bundles zurückgegeben:

Bundle

Bundle.identifier

Bundle.type

searchset

Bundle.timestamp

Bundle.total

Bundle.link

Bundle.link.relation

Bundle.link.url

Bundle.entry

Bundle.entry.link

Bundle.entry.fullUrl

Bundle.entry.resource

Bundle.entry.search

Bundle.entry.search.mode

Bundle.entry.search.score

Bundle.entry.request

Bundle.entry.request.method

Bundle.entry.request.url

Bundle.entry.request.ifNoneMatch

Bundle.entry.request.ifModifiedSince

Bundle.entry.request.ifMatch

Bundle.entry.request.ifNoneExist

Bundle.entry.response

Bundle.entry.response.status

Bundle.entry.response.location

Bundle.entry.response.etag

Bundle.entry.response.lastModified

Bundle.entry.response.outcome

Bundle.entry:DocumentReference

Bundle.entry:DocumentReference.link

Bundle.entry:DocumentReference.fullUrl

Bundle.entry:DocumentReference.resource

Bundle.entry:DocumentReference.search

Bundle.entry:DocumentReference.search.mode

Bundle.entry:DocumentReference.search.score

Bundle.entry:DocumentReference.request

Bundle.entry:DocumentReference.request.method

Bundle.entry:DocumentReference.request.url

Bundle.entry:DocumentReference.request.ifNoneMatch

Bundle.entry:DocumentReference.request.ifModifiedSince

Bundle.entry:DocumentReference.request.ifMatch

Bundle.entry:DocumentReference.request.ifNoneExist

Bundle.entry:DocumentReference.response

Bundle.entry:DocumentReference.response.status

Bundle.entry:DocumentReference.response.location

Bundle.entry:DocumentReference.response.etag

Bundle.entry:DocumentReference.response.lastModified

Bundle.entry:DocumentReference.response.outcome

Bundle.signature

Suchergebnisse können zahlreich sein. Server MÜSSEN daher FHIR-konformes Paging unterstützen. Server KÖNNEN im SearchSet-Bundle auch Ressourcen vom Typ OperationOutcome mit Informationen über die Suchergebnisse zurückgeben. Diese müssen in Bundle.entry.search.mode mit dem Wert outcome gekennzeichnet sein. Die Issues im OperationOutcome dürfen nur dem Schweregrad information oder warning entsprechen. Issues vom Schweregrad error oder fatal sind unzulässig.

Hinweise und Anmerkungen zur Implementierung von IHE MHD ITI-67 (Find DocumentReferences)

Für die Implementierung der Interaktion "Dokumentenabfrage" gelten die in IHE MHD festgelegten Vereinbarungen zu ITI-67 (Find DocumentReferences) gemäß der unten aufgelisteten Kapitel. Abweichungen bzw. zusätzliche Festlegungen im Kontext von ISiK sind im Folgenden zu den einzelnen Kapiteln vermerkt.

2:3.67.4.1 Find Document References Request Message

2:3.67.4.1.1 Trigger Events

Die Vereinbarungen gelten uneingeschränkt.

2:3.67.4.1.2 Message Semantics

Es gelten darüber hinaus die allgemeinen Festlegungen zu Suchparametern gemäß ISiK Basisprofil Stufe 2

2:3.67.4.1.2.1 Query Search Parameters

Im Rahmen der ISiK-Spezifikation müssen mindestens die im Kapitel Interaktionen mit MUSS gekennzeichneten Suchparameter unterstützt werden. Einzelnen Systemen steht es frei, darüber hinaus weitere FHIR-konforme bzw in IHE MHD geforderte Suchparameter zu implementieren.

Die in IHE bestehende Verpflichtung für Clients, bei jeder Query mindestens einen der Parameter patient oder patient.identifier verwenden zu müssen, besteht im ISiK-Kontext nicht. Patientenübergreifende Suchanfragen sind zulässig.

2:3.67.4.1.2.2 Populating Expected Response Format

Die Vereinbarungen gelten uneingeschränkt.

2:3.67.4.1.3 Expected Actions

Die Vereinbarungen gelten uneingeschränkt.

2:3.67.4.1.3.1 XDS on FHIR Option

Die Implementierung der "XDS on FHIR"-Option ist im ISiK-Kontext nicht gefordert.

2:3.67.4.2 Find Document References Response Message

2:3.67.4.2.1 Trigger Events

Die Vereinbarungen gelten uneingeschränkt.

2:3.67.4.2.2 Message Semantics

• Suchergebnisse können zahlreich sein. Server MÜSSEN daher FHIR-konformes Paging unterstützen. Server KÖNNEN im * SearchSet-Bundle auch Ressourcen vom Typ OperationOutcome mit Informationen über die Suchergebnisse zurückgeben. Diese müssen in Bundle.entry.search.mode mit dem Wert outcome gekennzeichnet sein. Die Issues im OperationOutcome dürfen nur dem Schweregrad information oder warning entsprechen. Issues vom Schweregrad error oder fatal sind unzulässig.
• Das Ergebnis-Bundle der Suche muss konform sein zum Profil "ISiKDokumentenSuchergebnisse"

  Bundle	I		Bundle	There are no (further) constraints on this element Element Id Bundle Short description Contains a collection of resources Definition A container for a collection of resources. Data Type Bundle Constraints bdl-7:FullUrl must be unique in a bundle, or else entries with the same fullUrl must have different meta.versionId (except in history bundles) (type = 'history') or entry.where(fullUrl.exists()).select(fullUrl&resource.meta.versionId).isDistinct() bdl-9:A document must have an identifier with a system and a value type = 'document' implies (identifier.system.exists() and identifier.value.exists()) bdl-3:entry.request mandatory for batch/transaction/history, otherwise prohibited entry.all(request.exists() = (%resource.type = 'batch' or %resource.type = 'transaction' or %resource.type = 'history')) bdl-4:entry.response mandatory for batch-response/transaction-response/history, otherwise prohibited entry.all(response.exists() = (%resource.type = 'batch-response' or %resource.type = 'transaction-response' or %resource.type = 'history')) bdl-12:A message must have a MessageHeader as the first resource type = 'message' implies entry.first().resource.is(MessageHeader) bdl-1:total only when a search or history total.empty() or (type = 'searchset') or (type = 'history') bdl-2:entry.search only when a search entry.search.empty() or (type = 'searchset') bdl-11:A document must have a Composition as the first resource type = 'document' implies entry.first().resource.is(Composition) bdl-10:A document must have a date type = 'document' implies (timestamp.hasValue()) Mappings rim:Entity. Role, or Act v2:N/A rim:N/A cda:ClinicalDocument, if bundle.type = document
  identifier	Σ	0..1	Identifier	There are no (further) constraints on this element Element Id Bundle.identifier Short description Persistent identifier for the bundle Definition A persistent identifier for the bundle that won't change as a bundle is copied from server to server. Comments Persistent identity generally only matters for batches of type Document, Message, and Collection. It would not normally be populated for search and history results and servers ignore Bundle.identifier when processing batches and transactions. For Documents the .identifier SHALL be populated such that the .identifier is globally unique. Data Type Identifier Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a v2:CX / EI (occasionally, more often EI maps to a resource id or a URL) rim:II - The Identifier class is a little looser than the v3 type II because it allows URIs as well as registered OIDs or GUIDs. Also maps to Role[classCode=IDENT] servd:Identifier w5:FiveWs.identifier cda:ClinicalDocument.id
  type	Σ	1..1	codeBindingFixed Value	Element Id Bundle.type Short description document | message | transaction | transaction-response | batch | batch-response | history | searchset | collection Definition Indicates the purpose of this bundle - how it is intended to be used. Comments It's possible to use a bundle for other purposes (e.g. a document can be accepted as a transaction). This is primarily defined so that there can be specific rules for some of the bundle types. Data Type code Binding Indicates the purpose of a bundle - how it is intended to be used. BundleType (required) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Fixed Value searchset Mappings rim:n/a w5:FiveWs.class
  timestamp	Σ	0..1	instant	There are no (further) constraints on this element Element Id Bundle.timestamp Short description When the bundle was assembled Definition The date/time that the bundle was assembled - i.e. when the resources were placed in the bundle. Comments For many bundles, the timestamp is equal to .meta.lastUpdated, because they are not stored (e.g. search results). When a bundle is placed in a persistent store, .meta.lastUpdated will be usually be changed by the server. When the bundle is a message, a middleware agent altering the message (even if not stored) SHOULD update .meta.lastUpdated. .timestamp is used to track the original time of the Bundle, and SHOULD be populated. Usage: document : the date the document was created. Note: the composition may predate the document, or be associated with multiple documents. The date of the composition - the authoring time - may be earlier than the document assembly time message : the date that the content of the message was assembled. This date is not changed by middleware engines unless they add additional data that changes the meaning of the time of the message history : the date that the history was assembled. This time would be used as the _since time to ask for subsequent updates searchset : the time that the search set was assembled. Note that different pages MAY have different timestamps but need not. Having different timestamps does not imply that subsequent pages will represent or include changes made since the initial query transaction | transaction-response | batch | batch-response | collection : no particular assigned meaning The timestamp value should be greater than the lastUpdated and other timestamps in the resources in the bundle, and it should be equal or earlier than the .meta.lastUpdated on the Bundle itself. Data Type instant Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a w5:FiveWs.init cda:ClinicalDocument.effectiveTime
  total	Σ I	1..1	unsignedInt	There are no (further) constraints on this element Element Id Bundle.total Short description If search, the total number of matches Definition If a set of search matches, this is the total number of entries of type 'match' across all pages in the search. It does not include search.mode = 'include' or 'outcome' entries and it does not provide a count of the number of entries in the Bundle. Comments Only used if the bundle is a search result set. The total does not include resources such as OperationOutcome and included resources, only the total number of matching resources. Data Type unsignedInt Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  link	Σ	0..*	BackboneElement	There are no (further) constraints on this element Element Id Bundle.link Short description Links related to this Bundle Definition A series of links that provide context to this bundle. Comments Both Bundle.link and Bundle.entry.link are defined to support providing additional context when Bundles are used (e.g. HATEOAS). Bundle.entry.link corresponds to links found in the HTTP header if the resource in the entry was read directly. This specification defines some specific uses of Bundle.link for searching and paging, but no specific uses for Bundle.entry.link, and no defined function in a transaction - the meaning is implementation specific. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  relation	Σ	1..1	string	There are no (further) constraints on this element Element Id Bundle.link.relation Short description See http://www.iana.org/assignments/link-relations/link-relations.xhtml#link-relations-1 Definition A name which details the functional use for this link - see http://www.iana.org/assignments/link-relations/link-relations.xhtml#link-relations-1. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  url	Σ	1..1	uri	There are no (further) constraints on this element Element Id Bundle.link.url Short description Reference details for the link Definition The reference details for the link. Comments see http://en.wikipedia.org/wiki/Uniform_resource_identifier Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  entry	Σ I	0..*	BackboneElement	Element Id Bundle.entry Short description Entry in the bundle - will have a resource or information Definition An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only). Data Type BackboneElement Sliced: Unordered, Open, by resource(Profile) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) bdl-8:fullUrl cannot be a version specific reference fullUrl.contains('/_history/').not() bdl-5:must be a resource unless there's a request or response resource.exists() or request.exists() or response.exists() Mappings rim:n/a
  (All Slices)				There are no (further) constraints on this element
  link	Σ	0..*	see (link)	There are no (further) constraints on this element Element Id Bundle.entry.link Short description Links related to this entry Definition A series of links that provide context to this entry.
  fullUrl	Σ	1..1	uri	There are no (further) constraints on this element Element Id Bundle.entry.fullUrl Short description URI for resource (Absolute URL server address or URI for UUID/OID) Definition The Absolute URL for the resource. The fullUrl SHALL NOT disagree with the id in the resource - i.e. if the fullUrl is not a urn:uuid, the URL shall be version-independent URL consistent with the Resource.id. The fullUrl is a version independent reference to the resource. The fullUrl element SHALL have a value except that: fullUrl can be empty on a POST (although it does not need to when specifying a temporary id for reference in the bundle) Results from operations might involve resources that are not identified. Comments fullUrl might not be unique in the context of a resource. Note that since FHIR resources do not need to be served through the FHIR API, the fullURL might be a URN or an absolute URL that does not end with the logical id of the resource (Resource.id). However, but if the fullUrl does look like a RESTful server URL (e.g. meets the regex, then the 'id' portion of the fullUrl SHALL end with the Resource.id. Note that the fullUrl is not the same as the canonical URL - it's an absolute url for an endpoint serving the resource (these will happen to have the same value on the canonical server for the resource with the canonical URL). Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  resource	Σ	0..1	Resource	There are no (further) constraints on this element Element Id Bundle.entry.resource Short description A resource in the bundle Definition The Resource for the entry. The purpose/meaning of the resource is determined by the Bundle.type. Data Type Resource Mappings rim:Entity. Role, or Act
  search	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry.search Short description Search related information Definition Information about the search process that lead to the creation of this entry. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  mode	Σ	0..1	codeBinding	There are no (further) constraints on this element Element Id Bundle.entry.search.mode Short description match | include | outcome - why this is in the result set Definition Why this entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process. Comments There is only one mode. In some corner cases, a resource may be included because it is both a match and an include. In these circumstances, 'match' takes precedence. Data Type code Binding Why an entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process. SearchEntryMode (required) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  score	Σ	0..1	decimal	There are no (further) constraints on this element Element Id Bundle.entry.search.score Short description Search ranking (between 0 and 1) Definition When searching, the server's search ranking score for the entry. Comments Servers are not required to return a ranking score. 1 is most relevant, and 0 is least relevant. Often, search results are sorted by score, but the client may specify a different sort order. See Patient Match for the EMPI search which relates to this element. Data Type decimal Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  request	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry.request Short description Additional execution information (transaction/batch/history) Definition Additional information about how this entry should be processed as part of a transaction or batch. For history, it shows how the entry was processed to create the version contained in the entry. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  method	Σ	1..1	codeBinding	There are no (further) constraints on this element Element Id Bundle.entry.request.method Short description GET | HEAD | POST | PUT | DELETE | PATCH Definition In a transaction or batch, this is the HTTP action to be executed for this entry. In a history bundle, this indicates the HTTP action that occurred. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Binding HTTP verbs (in the HTTP command line). See [HTTP rfc](https://tools.ietf.org/html/rfc7231) for details. HTTPVerb (required) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  url	Σ	1..1	uri	There are no (further) constraints on this element Element Id Bundle.entry.request.url Short description URL for HTTP equivalent of this entry Definition The URL for this entry, relative to the root (the address to which the request is posted). Comments E.g. for a Patient Create, the method would be "POST" and the URL would be "Patient". For a Patient Update, the method would be PUT and the URL would be "Patient/[id]". Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifNoneMatch	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry.request.ifNoneMatch Short description For managing cache currency Definition If the ETag values match, return a 304 Not Modified status. See the API documentation for "Conditional Read". Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifModifiedSince	Σ	0..1	instant	There are no (further) constraints on this element Element Id Bundle.entry.request.ifModifiedSince Short description For managing cache currency Definition Only perform the operation if the last updated date matches. See the API documentation for "Conditional Read". Comments Note: This is intended for where precisely observed times are required, typically system logs etc., and not human-reported times - for them, see date and dateTime (which can be as precise as instant, but is not required to be) below. Time zone is always required Data Type instant Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifMatch	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry.request.ifMatch Short description For managing update contention Definition Only perform the operation if the Etag value matches. For more information, see the API section "Managing Resource Contention". Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifNoneExist	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry.request.ifNoneExist Short description For conditional creates Definition Instruct the server not to perform the create if a specified resource already exists. For further information, see the API documentation for "Conditional Create". This is just the query portion of the URL - what follows the "?" (not including the "?"). Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  response	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry.response Short description Results of execution (transaction/batch/history) Definition Indicates the results of processing the corresponding 'request' entry in the batch or transaction being responded to or what the results of an operation where when returning history. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  status	Σ	1..1	string	There are no (further) constraints on this element Element Id Bundle.entry.response.status Short description Status response code (text optional) Definition The status code returned by processing this entry. The status SHALL start with a 3 digit HTTP code (e.g. 404) and may contain the standard HTTP description associated with the status code. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  location	Σ	0..1	uri	There are no (further) constraints on this element Element Id Bundle.entry.response.location Short description The location (if the operation returns a location) Definition The location header created by processing this operation, populated if the operation returns a location. Comments see http://en.wikipedia.org/wiki/Uniform_resource_identifier Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  etag	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry.response.etag Short description The Etag for the resource (if relevant) Definition The Etag for the resource, if the operation for the entry produced a versioned resource (see Resource Metadata and Versioning and Managing Resource Contention). Comments Etags match the Resource.meta.versionId. The ETag has to match the version id in the header if a resource is included. Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  lastModified	Σ	0..1	instant	There are no (further) constraints on this element Element Id Bundle.entry.response.lastModified Short description Server's date time modified Definition The date/time that the resource was modified on the server. Comments This has to match the same time in the meta header (meta.lastUpdated) if a resource is included. Data Type instant Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  outcome	Σ	0..1	Resource	There are no (further) constraints on this element Element Id Bundle.entry.response.outcome Short description OperationOutcome with hints and warnings (for batch/transaction) Definition An OperationOutcome containing hints and warnings produced as part of processing this entry in a batch or transaction. Comments For a POST/PUT operation, this is the equivalent outcome that would be returned for prefer = operationoutcome - except that the resource is always returned whether or not the outcome is returned. This outcome is not used for error responses in batch/transaction, only for hints and warnings. In a batch operation, the error will be in Bundle.entry.response, and for transaction, there will be a single OperationOutcome instead of a bundle in the case of an error. Data Type Resource Mappings rim:Entity. Role, or Act
  DocumentReference	Σ I	0..*	BackboneElement	Element Id Bundle.entry:DocumentReference Short description DocumentReference Definition An entry in a bundle resource - will either contain a resource or information about a resource (transactions and history only). Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) bdl-8:fullUrl cannot be a version specific reference fullUrl.contains('/_history/').not() bdl-5:must be a resource unless there's a request or response resource.exists() or request.exists() or response.exists() Mappings rim:n/a
  link	Σ	0..*	see (link)	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.link Short description Links related to this entry Definition A series of links that provide context to this entry.
  fullUrl	Σ	0..1	uri	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.fullUrl Short description URI for resource (Absolute URL server address or URI for UUID/OID) Definition The Absolute URL for the resource. The fullUrl SHALL NOT disagree with the id in the resource - i.e. if the fullUrl is not a urn:uuid, the URL shall be version-independent URL consistent with the Resource.id. The fullUrl is a version independent reference to the resource. The fullUrl element SHALL have a value except that: fullUrl can be empty on a POST (although it does not need to when specifying a temporary id for reference in the bundle) Results from operations might involve resources that are not identified. Comments fullUrl might not be unique in the context of a resource. Note that since FHIR resources do not need to be served through the FHIR API, the fullURL might be a URN or an absolute URL that does not end with the logical id of the resource (Resource.id). However, but if the fullUrl does look like a RESTful server URL (e.g. meets the regex, then the 'id' portion of the fullUrl SHALL end with the Resource.id. Note that the fullUrl is not the same as the canonical URL - it's an absolute url for an endpoint serving the resource (these will happen to have the same value on the canonical server for the resource with the canonical URL). Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  resource	Σ I	1..1	Erforderliche Metadaten für Dokumentenaustausch in ISiK	Element Id Bundle.entry:DocumentReference.resource Short description A reference to a document Definition 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. Comments Usually, this is used for documents other than those defined by FHIR. Data Type Erforderliche Metadaten für Dokumentenaustausch in ISiK Constraints dom-2:If the resource is contained in another resource, it SHALL NOT contain nested Resources contained.contained.empty() dom-4: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-3: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-6:A resource should have narrative for robust management text.`div`.exists() dom-5:If a resource is contained in another resource, it SHALL NOT have a security label contained.meta.security.empty() Mappings rim:Entity. Role, or Act workflow:Event fhircomposition:when describing a Composition rim:Document[classCode="DOC" and moodCode="EVN"] cda:when describing a CDA
  search	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.search Short description Search related information Definition Information about the search process that lead to the creation of this entry. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  mode	Σ	0..1	codeBinding	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.search.mode Short description match | include | outcome - why this is in the result set Definition Why this entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process. Comments There is only one mode. In some corner cases, a resource may be included because it is both a match and an include. In these circumstances, 'match' takes precedence. Data Type code Binding Why an entry is in the result set - whether it's included as a match or because of an _include requirement, or to convey information or warning information about the search process. SearchEntryMode (required) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  score	Σ	0..1	decimal	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.search.score Short description Search ranking (between 0 and 1) Definition When searching, the server's search ranking score for the entry. Comments Servers are not required to return a ranking score. 1 is most relevant, and 0 is least relevant. Often, search results are sorted by score, but the client may specify a different sort order. See Patient Match for the EMPI search which relates to this element. Data Type decimal Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  request	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request Short description Additional execution information (transaction/batch/history) Definition Additional information about how this entry should be processed as part of a transaction or batch. For history, it shows how the entry was processed to create the version contained in the entry. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  method	Σ	1..1	codeBinding	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.method Short description GET | HEAD | POST | PUT | DELETE | PATCH Definition In a transaction or batch, this is the HTTP action to be executed for this entry. In a history bundle, this indicates the HTTP action that occurred. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type code Binding HTTP verbs (in the HTTP command line). See [HTTP rfc](https://tools.ietf.org/html/rfc7231) for details. HTTPVerb (required) Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  url	Σ	1..1	uri	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.url Short description URL for HTTP equivalent of this entry Definition The URL for this entry, relative to the root (the address to which the request is posted). Comments E.g. for a Patient Create, the method would be "POST" and the URL would be "Patient". For a Patient Update, the method would be PUT and the URL would be "Patient/[id]". Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifNoneMatch	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.ifNoneMatch Short description For managing cache currency Definition If the ETag values match, return a 304 Not Modified status. See the API documentation for "Conditional Read". Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifModifiedSince	Σ	0..1	instant	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.ifModifiedSince Short description For managing cache currency Definition Only perform the operation if the last updated date matches. See the API documentation for "Conditional Read". Comments Note: This is intended for where precisely observed times are required, typically system logs etc., and not human-reported times - for them, see date and dateTime (which can be as precise as instant, but is not required to be) below. Time zone is always required Data Type instant Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifMatch	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.ifMatch Short description For managing update contention Definition Only perform the operation if the Etag value matches. For more information, see the API section "Managing Resource Contention". Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  ifNoneExist	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.request.ifNoneExist Short description For conditional creates Definition Instruct the server not to perform the create if a specified resource already exists. For further information, see the API documentation for "Conditional Create". This is just the query portion of the URL - what follows the "?" (not including the "?"). Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  response	Σ I	0..1	BackboneElement	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response Short description Results of execution (transaction/batch/history) Definition Indicates the results of processing the corresponding 'request' entry in the batch or transaction being responded to or what the results of an operation where when returning history. Data Type BackboneElement Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  status	Σ	1..1	string	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response.status Short description Status response code (text optional) Definition The status code returned by processing this entry. The status SHALL start with a 3 digit HTTP code (e.g. 404) and may contain the standard HTTP description associated with the status code. Comments Note that FHIR strings SHALL NOT exceed 1MB in size Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  location	Σ	0..1	uri	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response.location Short description The location (if the operation returns a location) Definition The location header created by processing this operation, populated if the operation returns a location. Comments see http://en.wikipedia.org/wiki/Uniform_resource_identifier Data Type uri Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  etag	Σ	0..1	string	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response.etag Short description The Etag for the resource (if relevant) Definition The Etag for the resource, if the operation for the entry produced a versioned resource (see Resource Metadata and Versioning and Managing Resource Contention). Comments Etags match the Resource.meta.versionId. The ETag has to match the version id in the header if a resource is included. Data Type string Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  lastModified	Σ	0..1	instant	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response.lastModified Short description Server's date time modified Definition The date/time that the resource was modified on the server. Comments This has to match the same time in the meta header (meta.lastUpdated) if a resource is included. Data Type instant Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a
  outcome	Σ	0..1	Resource	There are no (further) constraints on this element Element Id Bundle.entry:DocumentReference.response.outcome Short description OperationOutcome with hints and warnings (for batch/transaction) Definition An OperationOutcome containing hints and warnings produced as part of processing this entry in a batch or transaction. Comments For a POST/PUT operation, this is the equivalent outcome that would be returned for prefer = operationoutcome - except that the resource is always returned whether or not the outcome is returned. This outcome is not used for error responses in batch/transaction, only for hints and warnings. In a batch operation, the error will be in Bundle.entry.response, and for transaction, there will be a single OperationOutcome instead of a bundle in the case of an error. Data Type Resource Mappings rim:Entity. Role, or Act
  signature	Σ	0..1	Signature	There are no (further) constraints on this element Element Id Bundle.signature Short description Digital Signature Definition Digital Signature - base64 encoded. XML-DSig or a JWT. Requirements A Signature holds an electronic representation of a signature and its supporting context in a FHIR accessible form. The signature may either be a cryptographic type (XML DigSig or a JWS), which is able to provide non-repudiation proof, or it may be a graphical image that represents a signature or a signature process. This element allows capturing signatures on documents, messages, transactions or even search responses, to support content-authentication, non-repudiation or other business cases. This is primarily relevant where the bundle may travel through multiple hops or via other mechanisms where HTTPS non-repudiation is insufficient. Comments The signature could be created by the "author" of the bundle or by the originating device. Requirements around inclusion of a signature, verification of signatures and treatment of signed/non-signed bundles is implementation-environment specific. Data Type Signature Constraints ele-1:All FHIR elements must have a @value or children hasValue() or (children().count() > id.count()) Mappings rim:n/a rim:N/A

2:3.67.4.2.2.1 DocumentReference Resource Contents

• Die DocumentReference-Ressoucen müssen im ISiK-Kontext auf Basis des Profils "ISiKDokumentenMetadaten" und den dort vereinbarten Kardinalitäten bzw. MustSupport-Flags erstellt werden.

2:3.67.4.2.2.1.1 Document Location

Die Vereinbarungen gelten uneingeschränkt.

Alle weiteren Unterkapitel von 2:3.67.4.2.2.1 DocumentReference Resource Contents sind für den ISiK-Kontext nicht relevant.

2:3.67.4.3 Expected Actions

Die Vereinbarungen gelten uneingeschränkt.

2:3.67.4.4 CapabilityStatement Resource

Es gelten die Vereinbarungen gemäß CapabilityStatement

2:3.67.5 Security Considerations

Für Hinweise zur Implementierung von Autorisation und Authentifikation im ISiK-Kontext, siehe Modul ISiK-Sicherheit

Beispiele

• Suche anhand von Patientenkontext (PID) und Dokumentendatum: [base]/DocumentReference?patient.identifier=1234&creation=gt2021-10-06
• Suche nach vorläufigen Endoskopiebefunden (anhand KDL-Dokumenttyp und docStatus): [base]/DocumentReference?type=http://dvmd.de/fhir/CodeSystem/kdl|DG02010&doc-status=preliminary
• Suche von Dokumenten anhand der Nummer des Abrechnungsfalles: [base]/DocumentReference?encounter.account:identifier=56789

Dokumentenzugriff (IHE MHD ITI-68 (Retrieve Document))

Das den Metadaten zugeordnete Dokument kann jeweils unter DocumentReference.content.attachment.url vom Server abgerufen werden.

Hinweise und Anmerkungen zur Implementierung von IHE MHD ITI-68 (Retrieve Document)

Für die Implementierung der Interaktion "Dokumentenzugriff" gelten die in IHE MHD festgelegten Vereinbarungen zu ITI-68 (Retrieve Document) gemäß der unten aufgelisteten Kapitel. Abweichungen bzw. zusätzliche Festlegungen im Kontext von ISiK sind im Folgenden zu den einzelnen Kapiteln vermerkt.

2:3.68.4.1 Retrieve Document Request Message

2:3.68.4.1.1 Trigger Events

Die Vereinbarungen gelten uneingeschränkt.

2:3.68.4.1.2 Message Semantics

Der einzige MIME-Type, den alle Dokumentenserver verpflichtend zurückgeben können MÜSSEN, ist der MIME Type, der dem DocumentReference.content.attachment.contentType entspricht.

Im ISiK-Kontext SOLLEN Dokumentenserver das Dokument darüber hinaus über einen Binary-Endpunkt bereitstellen können. Dieser verfügt über folgende Besonderheit:

• Wenn der Zugriff mit dem Accept-Header application/fhir+xml oder application/fhir+json erfolgt, müssen die Daten als Binary-Ressource im angeforderten Format zurückgegeben werden.
• Wenn der Zugriff mit einem anderen Accept-Header als application/fhir+xml oder application/fhir+json erfolgt, so soll das Dokument im angeforderten Format zurückgegeben werden, z.B. MUSS bei Zugriffen mit Accept-Header application/pdf das Dokument unmittelbar als PDF zurückgegeben werden, sofern dies dem Content-Type der Binary-Ressource entspricht.

2:3.68.4.1.3 Expected Actions

Die Vereinbarungen gelten uneingeschränkt.

2:3.68.4.2 Retrieve Document Response Message

Die Vereinbarungen dieses Kapitels und aller Unterkapitel gelten uneingeschränkt.

2:3.68.4.2.1 Trigger Events

Die Vereinbarungen gelten uneingeschränkt.

2:3.68.4.2.2 Message Semantics

Die Vereinbarungen gelten uneingeschränkt.

2:3.68.4.3 Expected Actions

Die Vereinbarungen gelten uneingeschränkt.

2:3.68.4.4 CapabilityStatement Resource

Es gelten die Vereinbarungen gemäß CapabilityStatement

2:3.68.5 Security Considerations

Für Hinweise zur Implementierung von Autorisation und Authentifikation im ISiK-Kontext, siehe Modul ISiK-Sicherheit