MII IG Kerndatensatz-Modul Bildgebung
2027.0.0-ballot.1 - Germany

MII IG Kerndatensatz-Modul Bildgebung - Downloaded Version 2027.0.0-ballot.1 See the Directory of published versions

Resource Profile: MII PR Bildgebung Semistrukturierter Befundbericht

Official URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-bildgebung/StructureDefinition/mii-pr-bildgebung-semistrukt-befundbericht Version: 2027.0.0-ballot.1
Active as of 2026-09-15 Computable Name: MII_PR_Bildgebung_Semistrukt_Befundbericht

The profile describes a semistructured report. It is an addition for the main medical report.

This Composition resource is used to record semi-structured diagnostic reports of imaging procedures.

The mapping of the dataset elements to this profile is documented in the Logical Model Bildgebung.

Examples

Example of a Composition resource representing the report in several sections. This offers the possibility to represent the report not only as free text or in structured form, but also chapter by chapter in a semi-structured form:

Composition-mii-exa-bildgebung-semistrukt-befundbericht

Usages:

You can also check for usages in the FHIR IG Statistics

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots, and their representations.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco 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()

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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

doco Documentation for this format
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco 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()

Summary

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

Structures

This structure refers to these other structures:

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

Key Elements View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco 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 View

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
.... 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

doco Documentation for this format

Snapshot ViewView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. 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
... 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

doco 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()

Summary

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

Structures

This structure refers to these other structures:

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

 

Other representations of profile: CSV, Excel, Schematron