Implementation Guide
TI Common
Version 1.5.0-ballot.1 - ballot

Ressourcenprofil: TI MHD Simplified Publish DocumentReference

Offizielle URL: https://gematik.de/fhir/ti/StructureDefinition/ti-mhd-simplified-publish-document-reference Version: 1.5.0
Active Stand: 2026-11-16 Maschinenlesbarer Name: TIMHDSimplifiedPublishDocumentReference

Copyright/Rechtliches: gematik GmbH / Dieses Artefakt ist lizenziert unter Apache License, Version 2.0.

Dieses Profil erweitert die IHE MHD Simplified Publish DocumentReference-Ressource für den TI-weiten Einsatz.

Usages:

  • This Profile is not used by any profiles in this Specification

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, ti-mhd-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..0 Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
.... identifier:uniqueId SΣN 0..1 UniqueIdIdentifier Unique identifier for the referenced Document
... status ?!SΣ 1..1 code Status des Dokuments
Binding: DocumentReferenceStatus (required): The status of the document reference.
Required Pattern: current
... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 SΣC 1..1 Reference(Patient) Systemweit eindeutige Kennung des Patienten
Constraints: ref-1
.... identifier SΣ 1..1 IdentifierKvid10 Logical reference, when literal reference is not known
... date SΣ 0..1 instant Wann die DocumentReference erzeugt wurde
... author SΣC 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
Constraints: ref-1
.... identifier SΣ 0..1 IdentifierKvid10, IdentifierTelematikId, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display SΣ 1..1 string Text alternative for the resource
... relatesTo SΣ 0..* BackboneElement Relationships to other documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: ref-1
..... identifier SΣ 0..1 EntryUUIDIdentifier Logical reference, when literal reference is not known
... securityLabel SΣ 1..* 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: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: att-1
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
Example General: en-AU
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size SΣ 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash SΣ 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context SΣ 1..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... period SΣC 0..1 Period Time of service that is being documented
Constraints: per-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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 SC 0..1 Reference(Patient) Patient demographics from source
Constraints: ref-1
..... reference SΣC 0..1 string Demographische Daten zum Patienten im Quellsystem
..... identifier SΣ 0..1 Identifier Kennung des Patienten im Quellsystem

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📦4.0.1 FHIR Std.
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown

Constraints

Id Grade Path(s) Description Expression
att-1 error DocumentReference.content.attachment If the Attachment has data, it SHALL have a contentType data.empty() or contentType.exists()
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()
per-1 error DocumentReference.context.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target, DocumentReference.context.sourcePatientInfo SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)

Diese Struktur ist abgeleitet von SimplifiedPublishDocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: ti-mhd-1
... masterIdentifier S 1..1 Identifier Master Version Specific Identifier
... status S 1..1 code Status des Dokuments
... type 1..1 CodeableConcept Art des Dokuments
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 S 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 Wann die DocumentReference erzeugt wurde
... author 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
.... identifier S 0..1 IdentifierKvid10, IdentifierTelematikId, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display S 1..1 string Text alternative for the resource
... relatesTo
.... code S 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target S 1..1 Reference(DocumentReference) Target of the relationship
..... identifier S 0..1 EntryUUIDIdentifier Logical reference, when literal reference is not known
... securityLabel 1..* CodeableConcept Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 S 1..1 BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
..... contentType S 1..1 code Mime type of the content, with charset etc.
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
..... language 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size S 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash S 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context S 1..1 BackboneElement Clinical context of document
.... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown

Constraints

Id Grade Path(s) Description Expression
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, ti-mhd-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... 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
Slice: Unordered, Open by value:url
... modifierExtension ?! 0..0 Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... Slices for identifier ΣN 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:type
.... identifier:uniqueId SΣN 0..1 UniqueIdIdentifier Unique identifier for the referenced Document
... status ?!SΣ 1..1 code Status des Dokuments
Binding: DocumentReferenceStatus (required): The status of the document reference.
Required Pattern: current
... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 SΣC 1..1 Reference(Patient) Systemweit eindeutige Kennung des Patienten
Constraints: ref-1
.... 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 Wann die DocumentReference erzeugt wurde
... author SΣC 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
Constraints: ref-1
.... 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, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display SΣ 1..1 string Text alternative for the resource
... authenticator C 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
Constraints: ref-1
... custodian C 0..1 Reference(Organization) Organization which maintains the document
Constraints: ref-1
... 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
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: ref-1
..... 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 EntryUUIDIdentifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* 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: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: att-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
Example General: en-AU
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size SΣ 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash SΣ 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context SΣ 1..1 BackboneElement Clinical context of 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter C 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
Constraints: ref-1
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period SΣC 0..1 Period Time of service that is being documented
Constraints: per-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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 SC 0..1 Reference(Patient) Patient demographics from source
Constraints: ref-1
..... 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 C 0..* Reference(Resource) Related identifiers or resources
Constraints: ref-1

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📦4.0.1 FHIR Std.
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.author.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.relatesTo.​target.type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v7.3
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown
DocumentReference.context.​sourcePatientInfo.type Base extensible ResourceType 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
att-1 error DocumentReference.content.attachment If the Attachment has data, it SHALL have a contentType data.empty() or contentType.exists()
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()
per-1 error DocumentReference.context.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error DocumentReference.subject, DocumentReference.author, DocumentReference.authenticator, DocumentReference.custodian, DocumentReference.relatesTo.target, DocumentReference.context.encounter, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, ti-mhd-1
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... modifierExtension ?! 0..0 Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
.... identifier:uniqueId SΣN 0..1 UniqueIdIdentifier Unique identifier for the referenced Document
... status ?!SΣ 1..1 code Status des Dokuments
Binding: DocumentReferenceStatus (required): The status of the document reference.
Required Pattern: current
... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 SΣC 1..1 Reference(Patient) Systemweit eindeutige Kennung des Patienten
Constraints: ref-1
.... identifier SΣ 1..1 IdentifierKvid10 Logical reference, when literal reference is not known
... date SΣ 0..1 instant Wann die DocumentReference erzeugt wurde
... author SΣC 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
Constraints: ref-1
.... identifier SΣ 0..1 IdentifierKvid10, IdentifierTelematikId, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display SΣ 1..1 string Text alternative for the resource
... relatesTo SΣ 0..* BackboneElement Relationships to other documents
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: ref-1
..... identifier SΣ 0..1 EntryUUIDIdentifier Logical reference, when literal reference is not known
... securityLabel SΣ 1..* 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: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 SΣ 1..1 BackboneElement Document referenced
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: att-1
..... contentType SΣ 1..1 code Mime type of the content, with charset etc.
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
Example General: en-AU
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size SΣ 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash SΣ 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context SΣ 1..1 BackboneElement Clinical context of document
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... period SΣC 0..1 Period Time of service that is being documented
Constraints: per-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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 SC 0..1 Reference(Patient) Patient demographics from source
Constraints: ref-1
..... reference SΣC 0..1 string Demographische Daten zum Patienten im Quellsystem
..... identifier SΣ 0..1 Identifier Kennung des Patienten im Quellsystem

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📦4.0.1 FHIR Std.
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown

Constraints

Id Grade Path(s) Description Expression
att-1 error DocumentReference.content.attachment If the Attachment has data, it SHALL have a contentType data.empty() or contentType.exists()
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()
per-1 error DocumentReference.context.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error DocumentReference.subject, DocumentReference.author, DocumentReference.relatesTo.target, DocumentReference.context.sourcePatientInfo SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)

Differential-Ansicht

Diese Struktur ist abgeleitet von SimplifiedPublishDocumentReference

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: ti-mhd-1
... masterIdentifier S 1..1 Identifier Master Version Specific Identifier
... status S 1..1 code Status des Dokuments
... type 1..1 CodeableConcept Art des Dokuments
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 S 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 Wann die DocumentReference erzeugt wurde
... author 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
.... identifier S 0..1 IdentifierKvid10, IdentifierTelematikId, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display S 1..1 string Text alternative for the resource
... relatesTo
.... code S 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target S 1..1 Reference(DocumentReference) Target of the relationship
..... identifier S 0..1 EntryUUIDIdentifier Logical reference, when literal reference is not known
... securityLabel 1..* CodeableConcept Vertraulichkeitskennzeichnung und Datenkategorie des Dokuments
.... coding S 0..* Coding Code defined by a terminology system
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 S 1..1 BackboneElement Document referenced
.... attachment S 1..1 Attachment Where to access the document
..... contentType S 1..1 code Mime type of the content, with charset etc.
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
..... language 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size S 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash S 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context S 1..1 BackboneElement Clinical context of document
.... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown

Constraints

Id Grade Path(s) Description Expression
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. DocumentReference C 0..* SimplifiedPublishDocumentReference A reference to a document
Constraints: dom-2, dom-3, dom-4, dom-5, dom-6, ti-mhd-1
... id Σ 0..1 id Logical id of this artifact
... meta Σ 0..1 Meta Metadata about the resource
... implicitRules ?!Σ 0..1 uri A set of rules under which this content was created
... 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
Slice: Unordered, Open by value:url
... modifierExtension ?! 0..0 Extensions that cannot be ignored
Slice: Unordered, Open by value:url
... masterIdentifier SΣ 1..1 Identifier Master Version Specific Identifier
... Slices for identifier ΣN 0..* Identifier Other identifiers for the document
Slice: Unordered, Open by value:type
.... identifier:uniqueId SΣN 0..1 UniqueIdIdentifier Unique identifier for the referenced Document
... status ?!SΣ 1..1 code Status des Dokuments
Binding: DocumentReferenceStatus (required): The status of the document reference.
Required Pattern: current
... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs (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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs (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 SΣC 1..1 Reference(Patient) Systemweit eindeutige Kennung des Patienten
Constraints: ref-1
.... 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 Wann die DocumentReference erzeugt wurde
... author SΣC 0..* Reference(Patient | Practitioner | Organization) Person oder System, welche(s) das Dokument erstellt hat - verpflichtend für Primärsysteme
Constraints: ref-1
.... 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, IdentifierLanr, IdentifierZanr Logical reference, when literal reference is not known
.... display SΣ 1..1 string Text alternative for the resource
... authenticator C 0..1 Reference(Practitioner | PractitionerRole | Organization) Who/what authenticated the document
Constraints: ref-1
... custodian C 0..1 Reference(Organization) Organization which maintains the document
Constraints: ref-1
... 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
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code SΣ 1..1 code replaces | transforms | signs | appends
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs (required)
.... target SΣC 1..1 Reference(DocumentReference) Target of the relationship
Constraints: ref-1
..... 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 EntryUUIDIdentifier Logical reference, when literal reference is not known
..... display Σ 0..1 string Text alternative for the resource
... description Σ 0..1 string Human-readable description
... securityLabel SΣ 1..* 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: https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs (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 SΣ 1..1 BackboneElement Document referenced
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... attachment SΣC 1..1 Attachment Where to access the document
Constraints: att-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs (required)
Example General: text/plain; charset=UTF-8, image/png
..... language SΣ 1..1 code Sprache, in der das Dokument abgefasst ist
Binding: https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs (required)
Example General: en-AU
..... data S 1..1 base64Binary The document is contained in the .data element, base64 encoded
..... size SΣ 1..1 unsignedInt Größe des Dokuments in Bytes
..... hash SΣ 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs (required)
... context SΣ 1..1 BackboneElement Clinical context of 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
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... encounter C 0..* Reference(Encounter | EpisodeOfCare) Context of the document content
Constraints: ref-1
.... event 0..* CodeableConcept Main clinical acts documented
Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
.... period SΣC 0..1 Period Time of service that is being documented
Constraints: per-1
..... 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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs (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 1..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: https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs (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 SC 0..1 Reference(Patient) Patient demographics from source
Constraints: ref-1
..... 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 C 0..* Reference(Resource) Related identifiers or resources
Constraints: ref-1

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
DocumentReference.language Base preferred Common Languages 📦4.0.1 FHIR Std.
DocumentReference.status Base required DocumentReferenceStatus 📍4.0.1 FHIR Std.
DocumentReference.type Base preferred Document Type Value Set 📦4.0.1 FHIR Std.
DocumentReference.type.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-type-code-vs Not State Unknown
DocumentReference.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
DocumentReference.category.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-class-code-vs Not State Unknown
DocumentReference.subject.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.author.​type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.relatesTo.​code Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-document-relationship-type-vs Not State Unknown
DocumentReference.relatesTo.​target.type Base extensible ResourceType 📍4.0.1 FHIR Std.
DocumentReference.securityLabel Base extensible SecurityLabels 📦4.0.1 FHIR Std.
DocumentReference.securityLabel.​coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-mhd-security-label-vs Not State Unknown
DocumentReference.content.​attachment.contentType Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-mime-type-vs Not State Unknown
DocumentReference.content.​attachment.language Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-language-code-vs Not State Unknown
DocumentReference.content.​format Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-format-code-vs Not State Unknown
DocumentReference.context.​event Base example v3 Code System ActCode 📦3.0.0 THO v7.3
DocumentReference.context.​facilityType Base example Facility Type Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​facilityType.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-healthcare-facility-type-code-vs Not State Unknown
DocumentReference.context.​practiceSetting Base example Practice Setting Code Value Set 📦4.0.1 FHIR Std.
DocumentReference.context.​practiceSetting.coding Base required https://gematik.de/fhir/terminology/ValueSet/epa-xds-practice-setting-code-vs Not State Unknown
DocumentReference.context.​sourcePatientInfo.type Base extensible ResourceType 📍4.0.1 FHIR Std.

Constraints

Id Grade Path(s) Description Expression
att-1 error DocumentReference.content.attachment If the Attachment has data, it SHALL have a contentType data.empty() or contentType.exists()
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()
per-1 error DocumentReference.context.period If present, start SHALL have a lower value than end start.hasValue().not() or end.hasValue().not() or (start <= end)
ref-1 error DocumentReference.subject, DocumentReference.author, DocumentReference.authenticator, DocumentReference.custodian, DocumentReference.relatesTo.target, DocumentReference.context.encounter, DocumentReference.context.sourcePatientInfo, DocumentReference.context.related SHALL have a contained resource if a local reference is provided reference.startsWith('#').not() or (reference.substring(1).trace('url') in %rootResource.contained.id.trace('ids'))
ti-mhd-1 error DocumentReference Der Identifier im Slice identifier:uniqueId muss mit masterIdentifier übereinstimmen, da beide auf DocumentEntry.uniqueId abgebildet werden (IHE MHD ab 4.2.4: "If this is present, then the identifier SHALL be the same as the one found in masterIdentifier."). identifier.where(type.coding.where(system = 'https://profiles.ihe.net/ITI/MHD/CodeSystem/IHE.MHD.MHDIdentifierType' and code = 'uniqueId').exists()).all(system = %resource.masterIdentifier.system and value = %resource.masterIdentifier.value)

 

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