A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

Usually, this is used for documents other than those defined by FHIR.

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

An Extension

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

CDA Document Id extension and root.

The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

Other identifiers associated with the document, including version independent identifiers.

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

Status des Dokuments (DocumentEntry.availabilityStatus) unter Berücksichtigung des MHD Mapping

Dies ist der Status des DocumentReference-Objekts, das unabhängig vom docStatus-Element ist.

Dieses Element wird als Modifier gekennzeichnet, da der Status Codes enthält, die das Dokument oder die Referenz als derzeit nicht gültig markieren.

n/a

n/a

Status of the underlying document.

Art des Dokuments (DocumentEntry.typeCode)

Das Attribut typeCode ist gemäß IHE XDS zwingend gefordert und kann zusätzlich zu (bzw. zusammen mit) dem classCode zur genaueren Klassifizierung des Dokuments genutzt werden, z.B. kann ein Dokument mit classCode 'Befundberichte' durch den typeCode als 'Pathologiebefundbericht' oder als 'Ergebnisse bildgebender Diagnostik' gekennzeichnet werden. Das Attribut typeCode stellt keine Spezialisierung von classCode dar. Somit kann ein bestimmter typeCode mit verschiedenen classCodes zur Beschreibung unterschiedlicher Dokumente kombiniert werden. Zum Beispiel haben ein Röntgenbild und der dazugehörige Radiologie-Befund den gleichen typeCode 'Ergebnisse bildgebender Diagnostik' aber zwei unterschiedliche classCodes, 'Bilddaten' bzw.'Befundberichte'. Daraus folgt, dass ein Dokument sowohl einem classCode als auch einem typeCode explizit zugeordnet werden muss; die Zuordnung zu einem typeCode allein reicht nicht aus, weil hierüber kein implizites Mapping auf einen einzigen 'übergeordneten' classCode möglich ist.

Precise type of clinical document.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Grobe Klassifizierung des Dokuments (DocumentEntry.classCode)

Das Attribut 'classCode' ist gemäß IHE XDS zwingend gefordert und erlaubt eine erste Klassifizierung der Dokumente in der XDS Document Registry in Dokumentenklassen, wie z.B. Briefe, Befundberichte oder Bilddaten. Die Wertemenge für diese Klassen sollte nicht zu detailliert sein, da im Attribut 'typeCode' eine weitere, verfeinerte Beschreibung der Dokumente erfolgt, die allerdings keine Spezialisierung des 'classCode' darstellen muss.

High-level kind of a clinical document at a macro level.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Systemweit eindeutige Kennung des Patienten (DocumentEntry.patientId)

EPAPatient|1.0.0

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

n/a

n/a

Person oder System, welche(s) das Dokument erstellt hat (DocumentEntry.author)

Logical Reference unter Nutzung der KVNR oder Telematik-ID

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

Rechtlich Verantwortlicher für das Dokument (DocumentEntry.legalAuthenticator)

Logical Reference unter Nutzung der Telematik-ID

An identifier for the target resource. This is used when there is no way to reference the other resource directly, either because the entity it represents is not available through a FHIR server, or because there is no way for the author of the resource to convert a known identifier to an actual location. There is no requirement that a Reference.identifier point to something that is actually exposed as a FHIR instance, but it SHALL point to a business concept that would be expected to be exposed as a FHIR instance, and that instance would need to be of a FHIR resource type allowed by the reference.

When an identifier is provided in place of a reference, any system processing the reference will only be able to resolve the identifier to a reference if it understands the business context in which the identifier is used. Sometimes this is global (e.g. a national identifier) but often it is not. For this reason, none of the useful mechanisms described for working with references (e.g. chaining, includes) are possible, nor should servers be expected to be able resolve the reference. Servers may accept an identifier based reference untouched, resolve it, and/or reject it - see CapabilityStatement.rest.resource.referencePolicy.

When both an identifier and a literal reference are provided, the literal reference is preferred. Applications processing the resource are allowed - but not required - to check that the identifier matches the literal reference

Applications converting a logical reference to a literal reference may choose to leave the logical reference present, or remove it.

Reference is intended to point to a structure that can potentially be expressed as a FHIR resource, though there is no need for it to exist as an actual FHIR resource instance - except in as much as an application wishes to actual find the target of the reference. The content referred to be the identifier must meet the logical constraints implied by any limitations on what resource types are permitted for the reference. For example, it would not be legitimate to send the identifier for a drug prescription if the type were Reference(Observation|DiagnosticReport). One of the use-cases for Reference.identifier is the situation where no FHIR representation exists (where the type is Reference (Any).

n/a

n/a

Relationships that this document has with other document references that already exist.

This element is labeled as a modifier because documents that append to other documents are incomplete on their own.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The type of relationship that this document has with anther document.

If this document appends another document, then the document cannot be fully understood without also accessing the referenced document.

The type of relationship between documents.

The target document of this relationship.

Ergänzende Hinweise in Freitext (DocumentEntry.comments)

n/a

Helps humans to assess whether the document is of interest.

Vertraulichkeitskennzeichnung des Dokuments (DocumentEntry.confidentialityCode)

Der Confidentiality Code drückt die Vertraulichkeitsstufe des Dokuments aus. Die Vertraulichkeitsstufe ist üblicherweise die Einschätzung des Autors oder des Einstellenden wie schützenswert das Dokument ist. Die Einschätzung des Autors oder Erstellers sollte erhalten bleiben, auch wenn die des Betroffenen (d.h. des Patienten) davon abweicht. Das heißt, dass man dem Dokument mehrere ConfidentialityCodes zuordnen können sollte. Dies unterstützt IHE XDS auch. Daher enthält das deutsche Value Set neben Codes der Autoreneinschätzung explizite Codes zur Betroffeneneinschätzung, die aus einem separaten, dediziertem Codesystem stammen. Die Datenkategorie des Dokuments entsprechend der ePA Legal Policy ist ebenso Bestandteil dieser Liste.

Security Labels from the Healthcare Privacy and Security Classification System.

Use of the Health Care Privacy/Security Classification (HCS) system of security-tag use is recommended.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The document and format referenced.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

The document or URL of the document along with critical metadata to prove content has integrity.

Identifies the type of the data in the attachment and allows a method to be chosen to interpret or render the data. Includes mime type parameters such as charset where appropriate.

Processors of the data need to be able to know how to interpret the data.

Sprache, in der das Dokument abgefasst ist (DocumentEntry.languageCode)

n/a

A human language.

Users need to be able to choose between the languages in a set of attachments.

The actual data of the attachment - a sequence of bytes, base64 encoded.

The base64-encoded data SHALL be expressed in the same character set as the base resource XML or JSON.

The data needs to able to be transmitted inline.

URI für das Dokument (DocumentEntry.URI)

Dateiname mit Extension ohne Pfadangabe

The data needs to be transmitted by reference.

Größe des Dokuments in Bytes (DocumentEntry.size)

n/a

Representing the size allows applications to determine whether they should fetch the content automatically in advance, or refuse to fetch it at all.

Kryptographische Prüfsumme des Dokuments (DocumentEntry.hash)

n/a

Included so that applications can verify that the contents of a location have not changed due to technical failures (e.g., storage rot, transport glitch, incorrect version).

Titel des Dokuments (DocumentEntry.title)

n/a

Applications need a label to display to a human user in place of the actual data if the data cannot be rendered or perceived by the viewer.

Erstellungszeitpunkt des Dokuments (DocumentEntry.creationTime)

n/a

This is often tracked as an integrity issue for use of the attachment.

Global eindeutiger Code für das Dokumentenformat (DocumentEntry.formatCode)

Das Attribut 'formatCode' spezifiziert das Format des Dokumentes. Zusammen mit dem typeCode (und ggf. mit dem mimeType) soll der formatCode für hinreichende Information sorgen, um einem Dokument-Konsumenten die Entscheidung zu ermöglichen, ob und wie er das Dokumentenformat verarbeiten kann.

The clinical context in which the document was prepared.

These values are primarily added to help with searching for interesting/relevant documents.

May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions.

Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself).

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions.

Describes the clinical encounter or type of care that the document content is associated with.

Ereignisse, die zur Erstellung des Dokuments geführt haben (DocumentEntry.eventCodeList)

Die eventCode Liste wurde konzipiert, um den medizinischen Kontext von Dokumenten abzubilden. Jedem Dokument können beliebig viele eventCodes zugeordnet werden. Zum Beispiel kann ein OP-Bericht über die eventCodeList mit je einem kodierten Wert für die durchgeführte Prozedur (z.B. Blinddarmentfernung) und die vorliegende Erkrankung (z.B. Appendizitis) versehen werden. Dies ermöglicht die Suche nach Dokumenten, die mit einer bestimmten Prozedur oder Diagnose zusammenhängen. Über den medizinischen Kontext hinaus kann das Attribut auch allgemein zur Kontextualisierung und zur Inhaltszusammenfassung verwendet werden.

This list of codes represents the main clinical acts being documented.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The time period over which the service that is described by the document was provided.

Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde (DocumentEntry.serviceStartTime)

n/a

Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde (DocumentEntry.serviceStopTime)

n/a

Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat (DocumentEntry.healthcareFacilityTypeCode)

DocumentEntry.healthcareFacilityTypeCode repräsentiert die Art der Einrichtung, in der die Tätigkeit stattfand, die zur Erzeugung des Dokuments führte. Zum Beispiel sollten Dokumente, die während eines ambulanten Falls in einem Krankenhaus entstehen, mit dem healthcareFacilityTypeCode für 'Krankenhaus' gekennzeichnet werden. Dabei ist zu beachten, dass es sich nicht notwendigerweise um die Art der Einrichtung handelt, in der das Dokument erstellt wurde. Beispielsweise ist es bei teleradiologischer Befundung eines Röntgenbildes für den healthcareFacilityTypeCode unerheblich, ob der befundende Radiologe in einem Krankenhaus oder in einer radiologischen Praxis ansässig ist; für den healthcareFacilityTypeCode wird die Einrichtungsart der Untersuchungsstelle (in der das Gerät betrieben wird) herangezogen.

XDS Facility Type.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat (DocumentEntry.practiceSettingCode)

DocumentEntry.practiceSettingCode spezifiziert die Fachrichtung der erstellenden Einrichtung. Typische Beispiele hierfür sind ärztliche Fachgebiete wie Allgemeinmedizin oder Radiologie. IHE International empfiehlt, dass die Codeliste zwischen 10 und 100 Codes umfassen sollte, so dass die Fachrichtung hinreichend genau abgebildet werden kann.

Additional details about where the content was created (e.g. clinical specialty).

This is an important piece of metadata that providers often rely upon to quickly sort and/or filter out to find specific content.

n/a

n/a

Allows for alternative encodings within a code system, and translations to other code systems.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

The Patient Information as known when the document was published. May be a reference to a version specific, or contained.

Demographische Daten zum Patienten im Quellsystem (DocumentEntry.sourcePatientInfo)

n/a

Kennung des Patienten im Quellsystem (DocumentEntry.sourcePatientId)

n/a

Liste von IDs, mit denen das Dokument assoziiert wird (DocumentEntry.referenceIdList)

n/a

Status des Dokuments (DocumentEntry.availabilityStatus) unter Berücksichtigung des MHD Mapping

Dies ist der Status des DocumentReference-Objekts, das unabhängig vom docStatus-Element ist.

Dieses Element wird als Modifier gekennzeichnet, da der Status Codes enthält, die das Dokument oder die Referenz als derzeit nicht gültig markieren.

n/a

n/a

Art des Dokuments (DocumentEntry.typeCode)

Das Attribut typeCode ist gemäß IHE XDS zwingend gefordert und kann zusätzlich zu (bzw. zusammen mit) dem classCode zur genaueren Klassifizierung des Dokuments genutzt werden, z.B. kann ein Dokument mit classCode 'Befundberichte' durch den typeCode als 'Pathologiebefundbericht' oder als 'Ergebnisse bildgebender Diagnostik' gekennzeichnet werden. Das Attribut typeCode stellt keine Spezialisierung von classCode dar. Somit kann ein bestimmter typeCode mit verschiedenen classCodes zur Beschreibung unterschiedlicher Dokumente kombiniert werden. Zum Beispiel haben ein Röntgenbild und der dazugehörige Radiologie-Befund den gleichen typeCode 'Ergebnisse bildgebender Diagnostik' aber zwei unterschiedliche classCodes, 'Bilddaten' bzw.'Befundberichte'. Daraus folgt, dass ein Dokument sowohl einem classCode als auch einem typeCode explizit zugeordnet werden muss; die Zuordnung zu einem typeCode allein reicht nicht aus, weil hierüber kein implizites Mapping auf einen einzigen 'übergeordneten' classCode möglich ist.

n/a

n/a

Grobe Klassifizierung des Dokuments (DocumentEntry.classCode)

Das Attribut 'classCode' ist gemäß IHE XDS zwingend gefordert und erlaubt eine erste Klassifizierung der Dokumente in der XDS Document Registry in Dokumentenklassen, wie z.B. Briefe, Befundberichte oder Bilddaten. Die Wertemenge für diese Klassen sollte nicht zu detailliert sein, da im Attribut 'typeCode' eine weitere, verfeinerte Beschreibung der Dokumente erfolgt, die allerdings keine Spezialisierung des 'classCode' darstellen muss.

n/a

n/a

Systemweit eindeutige Kennung des Patienten (DocumentEntry.patientId)

EPAPatient|1.0.0

n/a

n/a

Person oder System, welche(s) das Dokument erstellt hat (DocumentEntry.author)

Logical Reference unter Nutzung der KVNR oder Telematik-ID

Rechtlich Verantwortlicher für das Dokument (DocumentEntry.legalAuthenticator)

Logical Reference unter Nutzung der Telematik-ID

n/a

n/a

Ergänzende Hinweise in Freitext (DocumentEntry.comments)

n/a

Vertraulichkeitskennzeichnung des Dokuments (DocumentEntry.confidentialityCode)

Der Confidentiality Code drückt die Vertraulichkeitsstufe des Dokuments aus. Die Vertraulichkeitsstufe ist üblicherweise die Einschätzung des Autors oder des Einstellenden wie schützenswert das Dokument ist. Die Einschätzung des Autors oder Erstellers sollte erhalten bleiben, auch wenn die des Betroffenen (d.h. des Patienten) davon abweicht. Das heißt, dass man dem Dokument mehrere ConfidentialityCodes zuordnen können sollte. Dies unterstützt IHE XDS auch. Daher enthält das deutsche Value Set neben Codes der Autoreneinschätzung explizite Codes zur Betroffeneneinschätzung, die aus einem separaten, dediziertem Codesystem stammen. Die Datenkategorie des Dokuments entsprechend der ePA Legal Policy ist ebenso Bestandteil dieser Liste.

n/a

n/a

Sprache, in der das Dokument abgefasst ist (DocumentEntry.languageCode)

n/a

URI für das Dokument (DocumentEntry.URI)

Dateiname mit Extension ohne Pfadangabe

Größe des Dokuments in Bytes (DocumentEntry.size)

n/a

Kryptographische Prüfsumme des Dokuments (DocumentEntry.hash)

n/a

Titel des Dokuments (DocumentEntry.title)

n/a

Erstellungszeitpunkt des Dokuments (DocumentEntry.creationTime)

n/a

Global eindeutiger Code für das Dokumentenformat (DocumentEntry.formatCode)

Das Attribut 'formatCode' spezifiziert das Format des Dokumentes. Zusammen mit dem typeCode (und ggf. mit dem mimeType) soll der formatCode für hinreichende Information sorgen, um einem Dokument-Konsumenten die Entscheidung zu ermöglichen, ob und wie er das Dokumentenformat verarbeiten kann.

Ereignisse, die zur Erstellung des Dokuments geführt haben (DocumentEntry.eventCodeList)

Die eventCode Liste wurde konzipiert, um den medizinischen Kontext von Dokumenten abzubilden. Jedem Dokument können beliebig viele eventCodes zugeordnet werden. Zum Beispiel kann ein OP-Bericht über die eventCodeList mit je einem kodierten Wert für die durchgeführte Prozedur (z.B. Blinddarmentfernung) und die vorliegende Erkrankung (z.B. Appendizitis) versehen werden. Dies ermöglicht die Suche nach Dokumenten, die mit einer bestimmten Prozedur oder Diagnose zusammenhängen. Über den medizinischen Kontext hinaus kann das Attribut auch allgemein zur Kontextualisierung und zur Inhaltszusammenfassung verwendet werden.

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Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde (DocumentEntry.serviceStartTime)

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Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde (DocumentEntry.serviceStopTime)

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Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat (DocumentEntry.healthcareFacilityTypeCode)

DocumentEntry.healthcareFacilityTypeCode repräsentiert die Art der Einrichtung, in der die Tätigkeit stattfand, die zur Erzeugung des Dokuments führte. Zum Beispiel sollten Dokumente, die während eines ambulanten Falls in einem Krankenhaus entstehen, mit dem healthcareFacilityTypeCode für 'Krankenhaus' gekennzeichnet werden. Dabei ist zu beachten, dass es sich nicht notwendigerweise um die Art der Einrichtung handelt, in der das Dokument erstellt wurde. Beispielsweise ist es bei teleradiologischer Befundung eines Röntgenbildes für den healthcareFacilityTypeCode unerheblich, ob der befundende Radiologe in einem Krankenhaus oder in einer radiologischen Praxis ansässig ist; für den healthcareFacilityTypeCode wird die Einrichtungsart der Untersuchungsstelle (in der das Gerät betrieben wird) herangezogen.

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Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat (DocumentEntry.practiceSettingCode)

DocumentEntry.practiceSettingCode spezifiziert die Fachrichtung der erstellenden Einrichtung. Typische Beispiele hierfür sind ärztliche Fachgebiete wie Allgemeinmedizin oder Radiologie. IHE International empfiehlt, dass die Codeliste zwischen 10 und 100 Codes umfassen sollte, so dass die Fachrichtung hinreichend genau abgebildet werden kann.

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Demographische Daten zum Patienten im Quellsystem (DocumentEntry.sourcePatientInfo)

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Kennung des Patienten im Quellsystem (DocumentEntry.sourcePatientId)

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Liste von IDs, mit denen das Dokument assoziiert wird (DocumentEntry.referenceIdList)

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A reference to a document of any kind for any purpose. Provides metadata about the document so that the document can be discovered and managed. The scope of a document is any seralized object with a mime-type, so includes formal patient centric documents (CDA), cliical notes, scanned paper, and non-patient specific documents like policy text.

Usually, this is used for documents other than those defined by FHIR.

The logical id of the resource, as used in the URL for the resource. Once assigned, this value never changes.

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

The metadata about the resource. This is content that is maintained by the infrastructure. Changes to the content might not always be associated with version changes to the resource.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The version specific identifier, as it appears in the version portion of the URL. This value changes when the resource is created, updated, or deleted.

The server assigns this value, and ignores what the client specifies, except in the case that the server is imposing version integrity on updates/deletes.

When the resource last changed - e.g. when the version changed.

This value is always populated except when the resource is first being created. The server / resource manager sets this value; what a client provides is irrelevant. This is equivalent to the HTTP Last-Modified and SHOULD have the same value on a read interaction.

A uri that identifies the source system of the resource. This provides a minimal amount of Provenance information that can be used to track or differentiate the source of information in the resource. The source may identify another FHIR server, document, message, database, etc.

In the provenance resource, this corresponds to Provenance.entity.what[x]. The exact use of the source (and the implied Provenance.entity.role) is left to implementer discretion. Only one nominated source is allowed; for additional provenance details, a full Provenance resource should be used.

This element can be used to indicate where the current master source of a resource that has a canonical URL if the resource is no longer hosted at the canonical URL.

A list of profiles (references to StructureDefinition resources) that this resource claims to conform to. The URL is a reference to StructureDefinition.url.

It is up to the server and/or other infrastructure of policy to determine whether/how these claims are verified and/or updated over time. The list of profile URLs is a set.

Security labels applied to this resource. These tags connect specific resources to the overall security policy and infrastructure.

The security labels can be updated without changing the stated version of the resource. The list of security labels is a set. Uniqueness is based the system/code, and version and display are ignored.

Security Labels from the Healthcare Privacy and Security Classification System.

Tags applied to this resource. Tags are intended to be used to identify and relate resources to process and workflow, and applications are not required to consider the tags when interpreting the meaning of a resource.

The tags can be updated without changing the stated version of the resource. The list of tags is a set. Uniqueness is based the system/code, and version and display are ignored.

Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".

A reference to a set of rules that were followed when the resource was constructed, and which must be understood when processing the content. Often, this is a reference to an implementation guide that defines the special rules along with other profiles etc.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element. Often, when used, the URL is a reference to an implementation guide that defines these special rules as part of it's narrative along with other profiles, value sets, etc.

The base language in which the resource is written.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource. Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

A human language.

A human-readable narrative that contains a summary of the resource and can be used to represent the content of the resource to a human. The narrative need not encode all the structured data, but is required to contain sufficient detail to make it "clinically safe" for a human to just read the narrative. Resource definitions may define what content should be represented in the narrative to ensure clinical safety.

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded information is added later.

These resources do not have an independent existence apart from the resource that contains them - they cannot be identified independently, and nor can they have their own independent transaction scope.

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again. Contained resources may have profiles and tags In their meta elements, but SHALL NOT have security labels.

May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

An Extension

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

CDA Document Id extension and root.

The structure and format of this Id shall be consistent with the specification corresponding to the formatCode attribute. (e.g. for a DICOM standard document a 64-character numeric UID, for an HL7 CDA format a serialization of the CDA Document Id extension and root in the form "oid^extension", where OID is a 64 digits max, and the Id is a 16 UTF-8 char max. If the OID is coded without the extension then the '^' character shall not be included.).

Other identifiers associated with the document, including version independent identifiers.

An identifier - identifies some entity uniquely and unambiguously. Typically this is used for business identifiers.

Status des Dokuments (DocumentEntry.availabilityStatus) unter Berücksichtigung des MHD Mapping

Dies ist der Status des DocumentReference-Objekts, das unabhängig vom docStatus-Element ist.

Dieses Element wird als Modifier gekennzeichnet, da der Status Codes enthält, die das Dokument oder die Referenz als derzeit nicht gültig markieren.

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Status of the underlying document.

Art des Dokuments (DocumentEntry.typeCode)

Das Attribut typeCode ist gemäß IHE XDS zwingend gefordert und kann zusätzlich zu (bzw. zusammen mit) dem classCode zur genaueren Klassifizierung des Dokuments genutzt werden, z.B. kann ein Dokument mit classCode 'Befundberichte' durch den typeCode als 'Pathologiebefundbericht' oder als 'Ergebnisse bildgebender Diagnostik' gekennzeichnet werden. Das Attribut typeCode stellt keine Spezialisierung von classCode dar. Somit kann ein bestimmter typeCode mit verschiedenen classCodes zur Beschreibung unterschiedlicher Dokumente kombiniert werden. Zum Beispiel haben ein Röntgenbild und der dazugehörige Radiologie-Befund den gleichen typeCode 'Ergebnisse bildgebender Diagnostik' aber zwei unterschiedliche classCodes, 'Bilddaten' bzw.'Befundberichte'. Daraus folgt, dass ein Dokument sowohl einem classCode als auch einem typeCode explizit zugeordnet werden muss; die Zuordnung zu einem typeCode allein reicht nicht aus, weil hierüber kein implizites Mapping auf einen einzigen 'übergeordneten' classCode möglich ist.

Precise type of clinical document.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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Allows for alternative encodings within a code system, and translations to other code systems.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.

Need to be unambiguous about the source of the definition of the symbol.

The version of the code system which was used when choosing this code. Note that a well-maintained code system does not need the version reported, because the meaning of codes is consistent across versions. However this cannot consistently be assured, and when the meaning is not guaranteed to be consistent, the version SHOULD be exchanged.

Where the terminology does not clearly define what string should be used to identify code system versions, the recommendation is to use the date (expressed in FHIR date format) on which that version was officially published as the version date.

A symbol in syntax defined by the system. The symbol may be a predefined code or an expression in a syntax defined by the coding system (e.g. post-coordination).

Need to refer to a particular code in the system.

A representation of the meaning of the code in the system, following the rules of the system.

Need to be able to carry a human-readable meaning of the code for readers that do not know the system.

Indicates that this coding was chosen by a user directly - e.g. off a pick list of available items (codes or displays).

Amongst a set of alternatives, a directly chosen code is the most appropriate starting point for new translations. There is some ambiguity about what exactly 'directly chosen' implies, and trading partner agreement may be needed to clarify the use of this element and its consequences more completely.

This has been identified as a clinical safety criterium - that this exact system/code pair was chosen explicitly, rather than inferred by the system based on some rules or language processing.

A human language representation of the concept as seen/selected/uttered by the user who entered the data and/or which represents the intended meaning of the user.

Very often the text is the same as a displayName of one of the codings.

The codes from the terminologies do not always capture the correct meaning with all the nuances of the human using them, or sometimes there is no appropriate code at all. In these cases, the text is used to capture the full meaning of the source.

Grobe Klassifizierung des Dokuments (DocumentEntry.classCode)

Das Attribut 'classCode' ist gemäß IHE XDS zwingend gefordert und erlaubt eine erste Klassifizierung der Dokumente in der XDS Document Registry in Dokumentenklassen, wie z.B. Briefe, Befundberichte oder Bilddaten. Die Wertemenge für diese Klassen sollte nicht zu detailliert sein, da im Attribut 'typeCode' eine weitere, verfeinerte Beschreibung der Dokumente erfolgt, die allerdings keine Spezialisierung des 'classCode' darstellen muss.

High-level kind of a clinical document at a macro level.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

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Allows for alternative encodings within a code system, and translations to other code systems.

Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.

May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

The identification of the code system that defines the meaning of the symbol in the code.

The URI may be an OID (urn:oid:...) or a UUID (urn:uuid:...). OIDs and UUIDs SHALL be references to the HL7 OID registry. Otherwise, the URI should come from HL7's list of FHIR defined special URIs or it should reference to some definition that establishes the system clearly and unambiguously.