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Resource Profile: EPA MHD DocumentReference

Dieses Profil erweitert die IHE MHD Minimal DocumentReference-Ressource mit ePA 3.0 Metadaten-Einschränkungen.

Usages:

• Use this Profile: EPA Document Search Result Bundle
• Examples for this Profile: DocumentReference/b2d5f8db-48ca-43c4-a540-6c8f2e853913
• CapabilityStatements using this Profile: EPA MHD Service (Document Consumer - Client) and ePA MHD Service (Document Responder - Server)

Formal Views of Profile Content

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

• Key Elements Table
• Differential Table
• Snapshot Table
• Statistics/References
• All

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
Slices for identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	?!SΣ	1..1	code	Status des Dokuments Binding: MHD DocumentReference status codes (required)
type	SΣ	1..1	CodeableConcept	Art des Dokuments Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
category	SΣ	1..1	CodeableConcept	Grobe Klassifizierung des Dokuments Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
subject	SΣ	1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
identifier	SΣ	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
date	SΣ	0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author	SΣ	1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
identifier	SΣ	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
identifier	SΣ	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
relatesTo	SΣ	0..*	BackboneElement	Relationships to other documents
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	SΣ	0..1	string	Ergänzende Hinweise in Freitext
securityLabel	SΣ	0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
content	Σ	1..1	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required) Example General: text/plain; charset=UTF-8, image/png
language	SΣ	1..1	code	Sprache, in der das Dokument abgefasst ist Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	SΣ	1..1	url	URI für das Dokument Example General: http://www.acme.com/logo-small.png
size	SΣ	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	SΣ	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	SΣ	1..1	string	Titel des Dokuments Example General: Official Corporate Logo
creation	SΣ	1..1	dateTime	Erstellungszeitpunkt des Dokuments
format	SΣ	1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context	Σ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
period	SΣ	0..1	Period	Time of service that is being documented
start	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType	S	1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
practiceSetting	S	0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
sourcePatientInfo	S	0..1	Reference(Patient)	Patient demographics from source
reference	SΣC	0..1	string	Demographische Daten zum Patienten im Quellsystem
identifier	SΣ	0..1	Identifier	Kennung des Patienten im Quellsystem
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStats https://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes From the FHIR Standard
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs

Constraints

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

This structure is derived from MinimalDocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
meta
profile		0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
identifier		0..*	Identifier	Other identifiers for the document
Slices for identifier				Content/Rules for all slices
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	S	1..1	code	Status des Dokuments
docStatus		0..0	code
type		1..1	CodeableConcept	Art des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
category		1..1	CodeableConcept	Grobe Klassifizierung des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
subject		1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
identifier	S	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
date		0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author		1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
identifier	S	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
identifier	S	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
custodian		0..0
relatesTo		0..*	BackboneElement	Relationships to other documents
description	S	0..1	string	Ergänzende Hinweise in Freitext
securityLabel		0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
content
attachment
contentType	S	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required)
language		1..1	code	Sprache, in der das Dokument abgefasst ist
url	S	1..1	url	URI für das Dokument
size	S	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	S	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	S	1..1	string	Titel des Dokuments
creation		1..1	dateTime	Erstellungszeitpunkt des Dokuments
format		1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context
encounter		0..0
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
period
start	S	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	S	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType		1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
practiceSetting		0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
sourcePatientInfo
reference	S	0..1	string	Demographische Daten zum Patienten im Quellsystem
identifier	S	0..1	Identifier	Kennung des Patienten im Quellsystem
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
Slices for identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	?!SΣ	1..1	code	Status des Dokuments Binding: MHD DocumentReference status codes (required)
type	SΣ	1..1	CodeableConcept	Art des Dokuments Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	SΣ	1..1	CodeableConcept	Grobe Klassifizierung des Dokuments Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
date	SΣ	0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author	SΣ	1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
relatesTo	SΣ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	SΣ	0..1	string	Ergänzende Hinweise in Freitext
securityLabel	SΣ	0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
content	Σ	1..1	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required) Example General: text/plain; charset=UTF-8, image/png
language	SΣ	1..1	code	Sprache, in der das Dokument abgefasst ist Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	SΣ	1..1	url	URI für das Dokument Example General: http://www.acme.com/logo-small.png
size	SΣ	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	SΣ	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	SΣ	1..1	string	Titel des Dokuments Example General: Official Corporate Logo
creation	SΣ	1..1	dateTime	Erstellungszeitpunkt des Dokuments
format	SΣ	1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
period	SΣ	0..1	Period	Time of service that is being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType	S	1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
practiceSetting	S	0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
sourcePatientInfo	S	0..1	Reference(Patient)	Patient demographics from source
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	0..1	string	Demographische Daten zum Patienten im Quellsystem
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	0..1	Identifier	Kennung des Patienten im Quellsystem
display	Σ	0..1	string	Text alternative for the resource
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStats https://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes From the FHIR Standard
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.authenticator.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs
DocumentReference.context.sourcePatientInfo.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard

Constraints

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

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 9 elements(20 nested mandatory elements)
Must-Support: 42 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

• Identifier-Profil für die 10-stellige Krankenversichertennummer (http://fhir.de/StructureDefinition/identifier-kvid-10)
• Identifier-Profil für die Telematik-ID (http://fhir.de/StructureDefinition/identifier-telematik-id)

Key Elements View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
Slices for identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	?!SΣ	1..1	code	Status des Dokuments Binding: MHD DocumentReference status codes (required)
type	SΣ	1..1	CodeableConcept	Art des Dokuments Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
category	SΣ	1..1	CodeableConcept	Grobe Klassifizierung des Dokuments Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
subject	SΣ	1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
identifier	SΣ	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
date	SΣ	0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author	SΣ	1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
identifier	SΣ	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
identifier	SΣ	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
relatesTo	SΣ	0..*	BackboneElement	Relationships to other documents
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	SΣ	0..1	string	Ergänzende Hinweise in Freitext
securityLabel	SΣ	0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
content	Σ	1..1	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required) Example General: text/plain; charset=UTF-8, image/png
language	SΣ	1..1	code	Sprache, in der das Dokument abgefasst ist Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	SΣ	1..1	url	URI für das Dokument Example General: http://www.acme.com/logo-small.png
size	SΣ	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	SΣ	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	SΣ	1..1	string	Titel des Dokuments Example General: Official Corporate Logo
creation	SΣ	1..1	dateTime	Erstellungszeitpunkt des Dokuments
format	SΣ	1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context	Σ	0..1	BackboneElement	Clinical context of document
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
period	SΣ	0..1	Period	Time of service that is being documented
start	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType	S	1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
practiceSetting	S	0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
sourcePatientInfo	S	0..1	Reference(Patient)	Patient demographics from source
reference	SΣC	0..1	string	Demographische Daten zum Patienten im Quellsystem
identifier	SΣ	0..1	Identifier	Kennung des Patienten im Quellsystem
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.status	required	DocumentReferenceStats https://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes From the FHIR Standard
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs

Constraints

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

Differential View

This structure is derived from MinimalDocumentReference

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
meta
profile		0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
identifier		0..*	Identifier	Other identifiers for the document
Slices for identifier				Content/Rules for all slices
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	S	1..1	code	Status des Dokuments
docStatus		0..0	code
type		1..1	CodeableConcept	Art des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
category		1..1	CodeableConcept	Grobe Klassifizierung des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
subject		1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
identifier	S	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
date		0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author		1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
identifier	S	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
identifier	S	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
custodian		0..0
relatesTo		0..*	BackboneElement	Relationships to other documents
description	S	0..1	string	Ergänzende Hinweise in Freitext
securityLabel		0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments
coding	S	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
content
attachment
contentType	S	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required)
language		1..1	code	Sprache, in der das Dokument abgefasst ist
url	S	1..1	url	URI für das Dokument
size	S	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	S	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	S	1..1	string	Titel des Dokuments
creation		1..1	dateTime	Erstellungszeitpunkt des Dokuments
format		1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context
encounter		0..0
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
period
start	S	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	S	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType		1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
practiceSetting		0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat
coding	S	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
display	S	1..1	string	Representation defined by the system
sourcePatientInfo
reference	S	0..1	string	Demographische Daten zum Patienten im Quellsystem
identifier	S	0..1	Identifier	Kennung des Patienten im Quellsystem
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet	URI
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs

Snapshot View

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	MinimalDocumentReference	A reference to a document
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
versionId	Σ	0..1	id	Version specific identifier
lastUpdated	Σ	0..1	instant	When the resource version last changed
source	Σ	0..1	uri	Identifies where the resource comes from
profile	Σ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
security	Σ	0..*	Coding	Security Labels applied to this resource Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
tag	Σ	0..*	Coding	Tags applied to this resource Binding: CommonTags (example): Codes that represent various types of tags, commonly workflow-related; e.g. "Needs review by Dr. Jones".
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation This profile does not constrain the narrative in regard to content, language, or traceability to data elements
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
masterIdentifier		1..1	UniqueIdIdentifier	An identifier intended for computation
Slices for identifier	SΣ	0..*	Identifier	Other identifiers for the document Slice: Unordered, Open by value:use
identifier:entryUUID	S	0..*	EntryUUIDIdentifier	An identifier intended for computation
status	?!SΣ	1..1	code	Status des Dokuments Binding: MHD DocumentReference status codes (required)
type	SΣ	1..1	CodeableConcept	Art des Dokuments Binding: DocumentTypeValueSet (preferred): Precise type of clinical document.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Type Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
category	SΣ	1..1	CodeableConcept	Grobe Klassifizierung des Dokuments Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Class Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	SΣ	1..1	Reference(Patient)	Systemweit eindeutige Kennung des Patienten
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	IdentifierKvid10	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
date	SΣ	0..1	instant	Das Erzeugungsdatum wird in content.attachment.creation abgebildet.
author	SΣ	1..*	Reference(Patient | Practitioner | Organization)	Person oder System, welche(s) das Dokument erstellt hat
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	0..1	IdentifierKvid10, IdentifierTelematikId	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
authenticator	S	0..1	Reference(Practitioner | Organization)	Rechtlich Verantwortlicher für das Dokument
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	1..1	IdentifierTelematikId	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
relatesTo	SΣ	0..*	BackboneElement	Relationships to other documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	Σ	1..1	Reference(DocumentReference)	Target of the relationship
description	SΣ	0..1	string	Ergänzende Hinweise in Freitext
securityLabel	SΣ	0..*	CodeableConcept	Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: MHD Security Label Value Set for ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
content	Σ	1..1	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	Σ	1..1	Attachment	Where to access the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	1..1	code	Mime type of the content, with charset etc. Binding: IHE XDS MIME Type ValueSet for ePA (required) Example General: text/plain; charset=UTF-8, image/png
language	SΣ	1..1	code	Sprache, in der das Dokument abgefasst ist Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	SΣ	1..1	url	URI für das Dokument Example General: http://www.acme.com/logo-small.png
size	SΣ	0..1	unsignedInt	Größe des Dokuments in Bytes
hash	SΣ	0..1	base64Binary	Kryptographische Prüfsumme des Dokuments
title	SΣ	1..1	string	Titel des Dokuments Example General: Official Corporate Logo
creation	SΣ	1..1	dateTime	Erstellungszeitpunkt des Dokuments
format	SΣ	1..1	Coding	Global eindeutiger Code für das Dokumentenformat Binding: IHE XDS Format Code ValueSet für ePA (required)
context	Σ	0..1	BackboneElement	Clinical context of document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
event	S	0..*	CodeableConcept	Ereignisse, die zur Erstellung des Dokuments geführt haben Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Event Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
period	SΣ	0..1	Period	Time of service that is being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis begonnen wurde
end	SΣC	0..1	dateTime	Zeitpunkt, an dem das im Dokument dokumentierte (Behandlungs-)Ereignis beendet wurde
facilityType	S	1..1	CodeableConcept	Art der Einrichtung, in der das dokumentierte Ereignis stattgefunden hat Binding: FacilityTypeCodeValueSet (example): XDS Facility Type.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Healthcare Facility Type Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
practiceSetting	S	0..1	CodeableConcept	Art der Fachrichtung der erstellenden Einrichtung, in der das dokumentiere Ereignis stattgefunden hat Binding: PracticeSettingCodeValueSet (example): Additional details about where the content was created (e.g. clinical specialty).
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	SΣ	0..*	Coding	Code defined by a terminology system Binding: IHE XDS Practice Setting Code ValueSet für ePA (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system
display	SΣ	1..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
sourcePatientInfo	S	0..1	Reference(Patient)	Patient demographics from source
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
reference	SΣC	0..1	string	Demographische Daten zum Patienten im Quellsystem
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	SΣ	0..1	Identifier	Kennung des Patienten im Quellsystem
display	Σ	0..1	string	Text alternative for the resource
related	S	0..*	Reference(Resource)	Liste von IDs, mit denen das Dokument assoziiert wird
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet	URI
DocumentReference.meta.security	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.meta.tag	example	CommonTags http://hl7.org/fhir/ValueSet/common-tags From the FHIR Standard
DocumentReference.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.status	required	DocumentReferenceStats https://profiles.ihe.net/ITI/MHD/ValueSet/DocumentReferenceStats
DocumentReference.type	preferred	DocumentTypeValueSet http://hl7.org/fhir/ValueSet/c80-doc-typecodes From the FHIR Standard
DocumentReference.type.coding	required	EPAXDSTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs
DocumentReference.category	example	DocumentClassValueSet http://hl7.org/fhir/ValueSet/document-classcodes From the FHIR Standard
DocumentReference.category.coding	required	EPAXDSClassCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs
DocumentReference.subject.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.author.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.authenticator.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard
DocumentReference.relatesTo.code	required	DocumentRelationshipType http://hl7.org/fhir/ValueSet/document-relationship-type|4.0.1 From the FHIR Standard
DocumentReference.securityLabel	extensible	All Security Labels http://hl7.org/fhir/ValueSet/security-labels From the FHIR Standard
DocumentReference.securityLabel.coding	required	EPAMHDSecurityLabelVS https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs
DocumentReference.content.attachment.contentType	required	EPAXDSMimeTypeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs
DocumentReference.content.attachment.language	preferred	CommonLanguages http://hl7.org/fhir/ValueSet/languages From the FHIR Standard Additional Bindings Purpose AllLanguages Max Binding
DocumentReference.content.format	required	EPAXDSFormatCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs
DocumentReference.context.event	example	ActCode http://terminology.hl7.org/ValueSet/v3-ActCode
DocumentReference.context.event.coding	required	EPAXDSEventCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-event-code-vs
DocumentReference.context.facilityType	example	FacilityTypeCodeValueSet http://hl7.org/fhir/ValueSet/c80-facilitycodes From the FHIR Standard
DocumentReference.context.facilityType.coding	required	EPAXDSHealthcareFacilityTypeCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs
DocumentReference.context.practiceSetting	example	PracticeSettingCodeValueSet http://hl7.org/fhir/ValueSet/c80-practice-codes From the FHIR Standard
DocumentReference.context.practiceSetting.coding	required	EPAXDSPracticeSettingCodeVS https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs
DocumentReference.context.sourcePatientInfo.type	extensible	ResourceType http://hl7.org/fhir/ValueSet/resource-types From the FHIR Standard

Constraints

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

This structure is derived from MinimalDocumentReference

Summary

Mandatory: 9 elements(20 nested mandatory elements)
Must-Support: 42 elements
Prohibited: 2 elements

Structures

This structure refers to these other structures:

• Identifier-Profil für die 10-stellige Krankenversichertennummer (http://fhir.de/StructureDefinition/identifier-kvid-10)
• Identifier-Profil für die Telematik-ID (http://fhir.de/StructureDefinition/identifier-telematik-id)