Diese Composition-Ressource wird verwendet, um semistrukturierte Befundberichte bildgebender Verfahren zu erfassen.

Die Zuordnung der Datensatz-Elemente zu diesem Profil ist im Logischen Modell Bildgebung dokumentiert.

Beispiele

Beispiel einer Composition-Ressource zur Darstellung des Befunds in verschiedenen Abschnitten. Dies bietet die Möglichkeit den Befund nicht nur als Freitext- oder in strukturierter Form, sondern auch in semi-strukturierter Form kapitelweise darzustellen.

Composition-mii-exa-bildgebung-semistrukt-befundbericht

• Schlüsselelemente-Tabelle
• Differential-Tabelle
• Snapshot-Tabelle
• Statistiken/Referenzen
• Alle

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	SΣ	0..1	id	Logical id of this artifact
meta	SΣ	0..1	Meta	Metadata about the resource
source	SΣ	0..1	uri	Identifies where the resource comes from
profile	SΣ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	Status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kompositionstyp Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
coding:loinc	SΣ	0..1	Coding	LOINC Code Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
version		0..1	string	Version of the system - if relevant
userSelected		0..1	boolean	If this coding was chosen directly by the user
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
subject	SΣ	1..1	Reference(Patient)	Person
date	SΣ	1..1	dateTime	Erstellungsdatum
author	SΣ	1..*	Reference(Practitioner)	Autor
title	SΣ	1..1	string	Titel
Slices for section	SC	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
coding	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	1..*	Reference(Resource)	Abschnittseintrag
section	SC	0..*	See section (Composition)	weiterer Abschnitt
section:diagRep	C	1..1	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
text		0..1	string	Plain text representation of the concept
coding	Σ	0..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
version		0..1	string	Version of the system - if relevant
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
section	SC	0..*	See section (Composition)	weiterer Abschnitt
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.

Constraints

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

Diese Struktur ist abgeleitet von Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	S	0..1	id	Logical id of this artifact
meta	S	0..1	Meta	Metadata about the resource
source	S	0..1	uri	Identifies where the resource comes from
profile	S	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
status	S	1..1	code	Status
type	S	1..1	CodeableConcept	Kompositionstyp
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
coding:loinc	S	0..1	Coding	LOINC Code Required Pattern: At least the following
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display		0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
subject	S	1..1	Reference(Patient)	Person
date	S	1..1	dateTime	Erstellungsdatum
author	S	1..*	Reference(Practitioner)	Autor
title	S	1..1	string	Titel
Slices for section	S	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code
section:All Slices				Content/Rules for all slices
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp
coding
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	S	0..1	Narrative	Abschnitttext
entry	S	1..*	Reference(Resource)	Abschnittseintrag
section	S	0..*		weiterer Abschnitt
section:diagRep		1..1	BackboneElement	Composition is broken into sections
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	S	0..1	Narrative	Abschnitttext
entry	S	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
section	S	0..*		weiterer Abschnitt
Documentation for this format

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	SΣ	0..1	id	Logical id of this artifact
meta	SΣ	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	SΣ	0..1	uri	Identifies where the resource comes from
profile	SΣ	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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!SΣ	1..1	code	Status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kompositionstyp Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	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	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
coding:loinc	SΣ	0..1	Coding	LOINC Code Required Pattern: At least the following
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 Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
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	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient)	Person
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Erstellungsdatum
author	SΣ	1..*	Reference(Practitioner)	Autor
title	SΣ	1..1	string	Titel
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	SC	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp Binding: DocumentSectionCodes (example): Classification of a section of a composition/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	Σ	0..*	Coding	Code defined by a terminology 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
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	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(Resource)	Abschnittseintrag
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	SC	0..*	See section (Composition)	weiterer Abschnitt
section:diagRep	C	1..1	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
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	Σ	0..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
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 Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
display	Σ	0..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
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
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	SC	0..*	See section (Composition)	weiterer Abschnitt
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.meta.security	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
Composition.meta.tag	Base	example	Common Tags	📍4.0.1	FHIR Std.
Composition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.attester.​mode	Base	required	CompositionAttestationMode	📍4.0.1	FHIR Std.
Composition.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
Composition.event.code	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.3
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:diagRep.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:diagRep.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.

Constraints

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

Schlüsselelemente-Ansicht

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	SΣ	0..1	id	Logical id of this artifact
meta	SΣ	0..1	Meta	Metadata about the resource
source	SΣ	0..1	uri	Identifies where the resource comes from
profile	SΣ	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!SΣ	1..1	code	Status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kompositionstyp Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
coding:loinc	SΣ	0..1	Coding	LOINC Code Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
version		0..1	string	Version of the system - if relevant
userSelected		0..1	boolean	If this coding was chosen directly by the user
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
subject	SΣ	1..1	Reference(Patient)	Person
date	SΣ	1..1	dateTime	Erstellungsdatum
author	SΣ	1..*	Reference(Practitioner)	Autor
title	SΣ	1..1	string	Titel
Slices for section	SC	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
coding	Σ	0..*	Coding	Code defined by a terminology system
system	SΣ	1..1	uri	Identity of the terminology system
code	SΣ	1..1	code	Symbol in syntax defined by the system
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	1..*	Reference(Resource)	Abschnittseintrag
section	SC	0..*	See section (Composition)	weiterer Abschnitt
section:diagRep	C	1..1	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
text		0..1	string	Plain text representation of the concept
coding	Σ	0..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
version		0..1	string	Version of the system - if relevant
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
userSelected		0..1	boolean	If this coding was chosen directly by the user
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
entry	SC	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
section	SC	0..*	See section (Composition)	weiterer Abschnitt
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.

Constraints

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

Differential-Ansicht

Diese Struktur ist abgeleitet von Composition

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	S	0..1	id	Logical id of this artifact
meta	S	0..1	Meta	Metadata about the resource
source	S	0..1	uri	Identifies where the resource comes from
profile	S	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
status	S	1..1	code	Status
type	S	1..1	CodeableConcept	Kompositionstyp
Slices for coding	S	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
coding:loinc	S	0..1	Coding	LOINC Code Required Pattern: At least the following
system	S	1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code	S	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display		0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
subject	S	1..1	Reference(Patient)	Person
date	S	1..1	dateTime	Erstellungsdatum
author	S	1..*	Reference(Practitioner)	Autor
title	S	1..1	string	Titel
Slices for section	S	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code
section:All Slices				Content/Rules for all slices
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp
coding
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	S	0..1	Narrative	Abschnitttext
entry	S	1..*	Reference(Resource)	Abschnittseintrag
section	S	0..*		weiterer Abschnitt
section:diagRep		1..1	BackboneElement	Composition is broken into sections
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
display		1..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
text	S	0..1	Narrative	Abschnitttext
entry	S	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
section	S	0..*		weiterer Abschnitt
Documentation for this format

Snapshot-AnsichtView

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
Composition		0..*	Composition	A set of resources composed into a single coherent clinical statement with clinical attestation
id	SΣ	0..1	id	Logical id of this artifact
meta	SΣ	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	SΣ	0..1	uri	Identifies where the resource comes from
profile	SΣ	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
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..1	Identifier	Version-independent identifier for the Composition
status	?!SΣ	1..1	code	Status Binding: CompositionStatus (required): The workflow/clinical status of the composition.
type	SΣ	1..1	CodeableConcept	Kompositionstyp Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	SΣ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by pattern:$this
coding:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	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	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
coding:loinc	SΣ	0..1	Coding	LOINC Code Required Pattern: At least the following
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 Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18748-4
display	Σ	0..1	string	Representation defined by the system Required Pattern: Diagnostic imaging study
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	Σ	0..*	CodeableConcept	Categorization of Composition Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
subject	SΣ	1..1	Reference(Patient)	Person
encounter	Σ	0..1	Reference(Encounter)	Context of the Composition
date	SΣ	1..1	dateTime	Erstellungsdatum
author	SΣ	1..*	Reference(Practitioner)	Autor
title	SΣ	1..1	string	Titel
confidentiality	Σ	0..1	code	As defined by affinity domain Binding: v3.ConfidentialityClassification (2014-03-26) (required): Codes specifying the level of confidentiality of the composition.
attester		0..*	BackboneElement	Attests to accuracy of composition
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
mode		1..1	code	personal | professional | legal | official Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
time		0..1	dateTime	When the composition was attested
party		0..1	Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization)	Who attested the composition
custodian	Σ	0..1	Reference(Organization)	Organization which maintains the composition
relatesTo		0..*	BackboneElement	Relationships to other compositions/documents
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code		1..1	code	replaces | transforms | signs | appends Binding: DocumentRelationshipType (required): The type of relationship between documents.
target[x]		1..1		Target of the relationship
targetIdentifier			Identifier
targetReference			Reference(Composition)
event	Σ	0..*	BackboneElement	The clinical service(s) being documented
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	Σ	0..*	CodeableConcept	Code(s) that apply to the event being documented Binding: v3 Code System ActCode (example): This list of codes represents the main clinical acts being documented.
period	Σ	0..1	Period	The period covered by the documentation
detail	Σ	0..*	Reference(Resource)	The event(s) being documented
Slices for section	SC	1..*	BackboneElement	Befundabschnitt Slice: Unordered, Open by value:code Constraints: cmp-1, cmp-2
section:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	0..1	CodeableConcept	Abschnitttyp Binding: DocumentSectionCodes (example): Classification of a section of a composition/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	Σ	0..*	Coding	Code defined by a terminology 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
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	Σ	0..1	string	Representation defined by the system
userSelected	Σ	0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(Resource)	Abschnittseintrag
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	SC	0..*	See section (Composition)	weiterer Abschnitt
section:diagRep	C	1..1	BackboneElement	Composition is broken into sections Constraints: cmp-1, cmp-2
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
title	S	0..1	string	Befundabschnittstitel
code	S	1..1	CodeableConcept	LOINC Code Binding: DocumentSectionCodes (example): Classification of a section of a composition/document. Required Pattern: At least the following
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	Σ	0..*	Coding	Code defined by a terminology system Fixed Value: (Complex)
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 Fixed Value: http://loinc.org
version	Σ	0..1	string	Version of the system - if relevant
code	SΣ	1..1	code	Symbol in syntax defined by the system Fixed Value: 18782-3
display	Σ	0..1	string	Representation defined by the system Fixed Value: Radiology Study observation (narrative)
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
author	S	0..*	Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization)	Abschnittsautor
focus		0..1	Reference(Resource)	Who/what the section is about, when it is not about the subject of composition
text	SC	0..1	Narrative	Abschnitttext This profile does not constrain the narrative in regard to content, language, or traceability to data elements
mode		0..1	code	working | snapshot | changes Binding: ListMode (required): The processing mode that applies to this section.
orderedBy		0..1	CodeableConcept	Order of section entries Binding: ListOrderCodes (preferred): What order applies to the items in the entry.
entry	SC	1..*	Reference(MII PR Bildgebung Radiologischer Befund)	Abschnittseintrag
emptyReason	C	0..1	CodeableConcept	Why the section is empty Binding: ListEmptyReasons (preferred): If a section is empty, why it is empty.
section	SC	0..*	See section (Composition)	weiterer Abschnitt
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
Composition.meta.security	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
Composition.meta.tag	Base	example	Common Tags	📍4.0.1	FHIR Std.
Composition.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
Composition.status	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
Composition.type	Base	preferred	FHIR Document Type Codes	📍4.0.1	FHIR Std.
Composition.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
Composition.confidentiality	Base	required	V3 Value SetConfidentialityClassification	📍2014-03-26	FHIR Std.
Composition.attester.​mode	Base	required	CompositionAttestationMode	📍4.0.1	FHIR Std.
Composition.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
Composition.event.code	Base	example	v3 Code System ActCode	📦3.0.0	THO v7.3
Composition.section.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.
Composition.section:diagRep.​code	Base	example	Document Section Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​mode	Base	required	ListMode	📍4.0.1	FHIR Std.
Composition.section:diagRep.​orderedBy	Base	preferred	List Order Codes	📍4.0.1	FHIR Std.
Composition.section:diagRep.​emptyReason	Base	preferred	List Empty Reasons	📍4.0.1	FHIR Std.

Constraints

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

Diese Struktur ist abgeleitet von Composition

Summary

Mandatory: 9 elements(4 nested mandatory elements)
Must-Support: 31 elements

Structures

This structure refers to these other structures:

• MII PR Bildgebung Radiologischer Befund (https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-radiologischer-befund)

Slices

This structure defines the following Slices:

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