This profile describes the metadata of a clinical document. A detailed description and recommendations for using the profile can be found in the module description.

Mapping of the dataset to FHIR

The complete mapping of the data elements of the logical model MII LM Dokument onto the elements of this DocumentReference profile is maintained in a single place and is shown on the Logical Models page.

Search parameters

The supported search parameters with example calls are on the Search Parameters page; the module's CapabilityStatement defines them normatively.

Examples

Extensive examples that illustrate the profile and the extension together can be found on the extension's page (MII EX Dokument NLP Processing Status).

An overview of all example instances of the module is on the Examples page.

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

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
meta	SΣ	0..1	Meta	Metadata about the resource
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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:nlp-processing-status	S	0..1	CodeableConcept	NLP Processing Status URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SΣ	0..1	Identifier	Specific Identifier for this version of the document
identifier	SΣ	0..*	Identifier	Further document associated Identifiers
status	?!SΣ	1..1	code	Status about the condition of the document reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	SΣ	0..1	code	Status about the referenced document itself Binding: CompositionStatus (required): Status of the underlying document.
type	SΣC	0..1	CodeableConcept	Precise description of the document type Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Constraints: mii-iv-dokument-dokument-type
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:KDL	SΣ	0..1	Coding	Code defined by a terminology system Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
code	SΣ	1..1	code	Symbol in syntax defined by the system
coding:LNC	SΣ	0..1	Coding	Code defined by a terminology system Binding: DocumentTypeValueSet (required)
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
coding:SCT	SΣ	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Typ (required)
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	SΣ	1..1	code	Symbol in syntax defined by the system
coding:XDS	SΣ	0..1	Coding	Code defined by a terminology system Binding: IHE XDS typeCode (required)
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
code	SΣ	1..1	code	Symbol in syntax defined by the system
category	SΣC	0..*	CodeableConcept	General description of the document type Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Constraints: mii-iv-dokument-dokument-category
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:LNC	SΣ	0..1	Coding	Code defined by a terminology system Binding: DocumentClassValueSet (required)
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
coding:SCT	SΣ	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Kategorie (required)
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code	SΣ	1..1	code	Symbol in syntax defined by the system
coding:XDS	SΣ	0..1	Coding	Code defined by a terminology system Binding: IHE XDS classCode (required)
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
code	SΣ	1..1	code	Symbol in syntax defined by the system
subject	SΣ	0..1	Reference(Patient | MII PR Person Patient(2027.0.0-ballot) | MII PR Person Patient (Pseudonymisiert)(2027.0.0-ballot))	Patient reference to the document
relatesTo	SΣ	0..*	BackboneElement	Document relationships
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
code	SΣ	1..1	code	Relationship to other document Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	SΣ	1..1	Reference(DocumentReference)	Target of document relations
description	SΣ	0..1	string	Description of the documents content
securityLabel	SΣ	0..*	CodeableConcept	Security level of the document Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for content	SΣ	1..*	BackboneElement	Document content Slice: Unordered, Open by exists:attachment.url
content:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Access to the document
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data		0..1	base64Binary	Document as binary data [Base64]
url	Σ	0..1	url	Link to the local location where the document is kept Example General: http://www.acme.com/logo-small.png
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
content:Binaerdaten	SΣ	0..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Access to the document
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data		1..1	base64Binary	Document as binary data [Base64]
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
content:Verweis	SΣ	0..*	BackboneElement	Document referenced
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Access to the document
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	Σ	1..1	url	Link to the local location where the document is kept Example General: http://www.acme.com/logo-small.png
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
context	SΣ	0..1	BackboneElement	Document creation context
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
encounter	S	0..*	Reference(Encounter | MII PR Fall Kontakt mit einer Gesundheitseinrichtung(2027.0.0-ballot))	Reference to FALL
event	S	0..*	CodeableConcept	Acts or procedures Binding: IHE XDS eventCodeList (required)
coding	Σ	1..*	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
period	SΣ	0..1	Period	Performance period
facilityType	S	0..1	CodeableConcept	Type of facility Binding: MII VS Dokument Einrichtungsart (required)
coding	Σ	1..*	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
practiceSetting	S	0..1	CodeableConcept	Clinical specialty Binding: MII VS Dokument Fachgebiet (required)
coding	Σ	1..*	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
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.type.​coding:KDL	Base	required	ValueSet Klinische Dokumentenklassen-Liste (Version 2025)	📦2025	dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:LNC	Base	required	Document Type Value Set	📦4.0.1	FHIR Std.
DocumentReference.type.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Typ	📦2027.0.0-ballot.2	This IG
DocumentReference.type.​coding:XDS	Base	required	IHE XDS typeCode	📦2020-02-07T07:55:58	de.ihe-d.terminology v3.0
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category.​coding:LNC	Base	required	Document Class Value Set	📦4.0.1	FHIR Std.
DocumentReference.category.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Kategorie	📦2027.0.0-ballot.2	This IG
DocumentReference.category.​coding:XDS	Base	required	IHE XDS classCode	📦2021-06-25T13:44:47	de.ihe-d.terminology v3.0
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.content:Binaerdaten.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:Binaerdaten.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:Binaerdaten.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.content:Verweis.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:Verweis.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:Verweis.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​event	Base	required	IHE XDS eventCodeList	📦2021-07-06T21:19:41	de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType	Base	required	MII VS Dokument Einrichtungsart	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​practiceSetting	Base	required	MII VS Dokument Fachgebiet	📦2027.0.0-ballot.2	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
mii-iv-dokument-dokument-category	warning	DocumentReference.category	Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein	coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDSclassCode').exists()
mii-iv-dokument-dokument-type	warning	DocumentReference.type	Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein	coding.where(system = 'http://dvmd.de/fhir/CodeSystem/kdl').exists() or coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDStypeCode').exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
meta	S	0..1	Meta	Metadata about the resource
profile	S	0..*	canonical(StructureDefinition)	Profiles this resource claims to conform to
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:nlp-processing-status	S	0..1	CodeableConcept	NLP Processing Status URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status
masterIdentifier	S	0..1	Identifier	Specific Identifier for this version of the document
identifier	S	0..*	Identifier	Further document associated Identifiers
status	S	1..1	code	Status about the condition of the document reference
docStatus	S	0..1	code	Status about the referenced document itself
type	SC	0..1	CodeableConcept	Precise description of the document type Constraints: mii-iv-dokument-dokument-type
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:KDL	S	0..1	Coding	Code defined by a terminology system Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
coding:LNC	S	0..1	Coding	Code defined by a terminology system Binding: DocumentTypeValueSet (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
coding:SCT	S	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Typ (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
coding:XDS	S	0..1	Coding	Code defined by a terminology system Binding: IHE XDS typeCode (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
category	SC	0..*	CodeableConcept	General description of the document type Constraints: mii-iv-dokument-dokument-category
Slices for coding		1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:LNC	S	0..1	Coding	Code defined by a terminology system Binding: DocumentClassValueSet (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://loinc.org
coding:SCT	S	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Kategorie (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
coding:XDS	S	0..1	Coding	Code defined by a terminology system Binding: IHE XDS classCode (required)
system		1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
subject	S	0..1	Reference(Patient | MII PR Person Patient(2027.0.0-ballot) | MII PR Person Patient (Pseudonymisiert)(2027.0.0-ballot))	Patient reference to the document
relatesTo	S	0..*	BackboneElement	Document relationships
code	S	1..1	code	Relationship to other document
target	S	1..1	Reference(DocumentReference)	Target of document relations
description	S	0..1	string	Description of the documents content
securityLabel	S	0..*	CodeableConcept	Security level of the document
Slices for content	S	1..*	BackboneElement	Document content Slice: Unordered, Open by exists:attachment.url
content:All Slices				Content/Rules for all slices
attachment	S	1..1	Attachment	Access to the document
contentType	S	0..1	code	MIME type of the document content
language	S	0..1	code	Used language in the document
data		0..1	base64Binary	Document as binary data [Base64]
url		0..1	url	Link to the local location where the document is kept
creation	S	0..1	dateTime	Date of the creation of the document
format	S	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
content:Binaerdaten	S	0..*	BackboneElement	Document referenced
attachment	S	1..1	Attachment	Access to the document
contentType	S	0..1	code	MIME type of the document content
language	S	0..1	code	Used language in the document
data		1..1	base64Binary	Document as binary data [Base64]
url		0..0		Link to the local location where the document is kept
creation	S	0..1	dateTime	Date of the creation of the document
format	S	0..1	Coding	Complex format specification
content:Verweis	S	0..*	BackboneElement	Document referenced
attachment	S	1..1	Attachment	Access to the document
contentType	S	0..1	code	MIME type of the document content
language	S	0..1	code	Used language in the document
data		0..0		Document as binary data [Base64]
url		1..1	url	Link to the local location where the document is kept
creation	S	0..1	dateTime	Date of the creation of the document
format	S	0..1	Coding	Complex format specification
context	S	0..1	BackboneElement	Document creation context
encounter	S	0..*	Reference(Encounter | MII PR Fall Kontakt mit einer Gesundheitseinrichtung(2027.0.0-ballot))	Reference to FALL
event	S	0..*	CodeableConcept	Acts or procedures Binding: IHE XDS eventCodeList (required)
coding		1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
period	S	0..1	Period	Performance period
facilityType	S	0..1	CodeableConcept	Type of facility Binding: MII VS Dokument Einrichtungsart (required)
coding		1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
practiceSetting	S	0..1	CodeableConcept	Clinical specialty Binding: MII VS Dokument Fachgebiet (required)
coding		1..*	Coding	Code defined by a terminology system
system	S	1..1	uri	Identity of the terminology system
code	S	1..1	code	Symbol in syntax defined by the system
Documentation for this format

Terminology Bindings (Differential)

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.type.​coding:KDL	Base	required	ValueSet Klinische Dokumentenklassen-Liste (Version 2025)	📦2025	dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:LNC	Base	required	Document Type Value Set	📦4.0.1	FHIR Std.
DocumentReference.type.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Typ	📦2027.0.0-ballot.2	This IG
DocumentReference.type.​coding:XDS	Base	required	IHE XDS typeCode	📦2020-02-07T07:55:58	de.ihe-d.terminology v3.0
DocumentReference.category.​coding:LNC	Base	required	Document Class Value Set	📦4.0.1	FHIR Std.
DocumentReference.category.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Kategorie	📦2027.0.0-ballot.2	This IG
DocumentReference.category.​coding:XDS	Base	required	IHE XDS classCode	📦2021-06-25T13:44:47	de.ihe-d.terminology v3.0
DocumentReference.content.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​event	Base	required	IHE XDS eventCodeList	📦2021-07-06T21:19:41	de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType	Base	required	MII VS Dokument Einrichtungsart	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​practiceSetting	Base	required	MII VS Dokument Fachgebiet	📦2027.0.0-ballot.2	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
mii-iv-dokument-dokument-category	warning	DocumentReference.category	Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein	coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDSclassCode').exists()
mii-iv-dokument-dokument-type	warning	DocumentReference.type	Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein	coding.where(system = 'http://dvmd.de/fhir/CodeSystem/kdl').exists() or coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDStypeCode').exists()

Name	Flags	Card.	Type	Description & Constraints    Filter: Bindings Constraints Obligations
DocumentReference		0..*	DocumentReference	A reference to a document
id	Σ	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	Σ	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
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
extension:nlp-processing-status	S	0..1	CodeableConcept	NLP Processing Status URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-dokument/StructureDefinition/mii-ex-dokument-nlp-processing-status
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
masterIdentifier	SΣ	0..1	Identifier	Specific Identifier for this version of the document
identifier	SΣ	0..*	Identifier	Further document associated Identifiers
status	?!SΣ	1..1	code	Status about the condition of the document reference Binding: DocumentReferenceStatus (required): The status of the document reference.
docStatus	SΣ	0..1	code	Status about the referenced document itself Binding: CompositionStatus (required): Status of the underlying document.
type	SΣC	0..1	CodeableConcept	Precise description of the document type Binding: DocumentTypeValueSet (preferred): Precise type of clinical document. Constraints: mii-iv-dokument-dokument-type
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
Slices for coding	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:KDL	SΣ	0..1	Coding	Code defined by a terminology system Binding: ValueSet Klinische Dokumentenklassen-Liste (Version 2025) (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
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:LNC	SΣ	0..1	Coding	Code defined by a terminology system Binding: DocumentTypeValueSet (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system 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
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:SCT	SΣ	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Typ (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
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:XDS	SΣ	0..1	Coding	Code defined by a terminology system Binding: IHE XDS typeCode (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
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
category	SΣC	0..*	CodeableConcept	General description of the document type Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level. Constraints: mii-iv-dokument-dokument-category
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	Σ	1..*	Coding	Code defined by a terminology system Slice: Unordered, Open by value:system
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:LNC	SΣ	0..1	Coding	Code defined by a terminology system Binding: DocumentClassValueSet (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system 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
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:SCT	SΣ	0..1	Coding	Code defined by a terminology system Binding: MII VS Dokument SCT Dokument Kategorie (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
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:XDS	SΣ	0..1	Coding	Code defined by a terminology system Binding: IHE XDS classCode (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
system	SΣ	1..1	uri	Identity of the terminology system Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
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
subject	SΣ	0..1	Reference(Patient | MII PR Person Patient(2027.0.0-ballot) | MII PR Person Patient (Pseudonymisiert)(2027.0.0-ballot))	Patient reference to the document
date	Σ	0..1	instant	When this document reference was created
author	Σ	0..*	Reference(Practitioner | PractitionerRole | Organization | Device | Patient | RelatedPerson)	Who and/or what authored the document
authenticator		0..1	Reference(Practitioner | PractitionerRole | Organization)	Who/what authenticated the document
custodian		0..1	Reference(Organization)	Organization which maintains the document
relatesTo	SΣ	0..*	BackboneElement	Document relationships
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	SΣ	1..1	code	Relationship to other document Binding: DocumentRelationshipType (required): The type of relationship between documents.
target	SΣ	1..1	Reference(DocumentReference)	Target of document relations
description	SΣ	0..1	string	Description of the documents content
securityLabel	SΣ	0..*	CodeableConcept	Security level of the document Binding: All Security Labels (extensible): Security Labels from the Healthcare Privacy and Security Classification System.
Slices for content	SΣ	1..*	BackboneElement	Document content Slice: Unordered, Open by exists:attachment.url
content: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
attachment	SΣ	1..1	Attachment	Access to the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data		0..1	base64Binary	Document as binary data [Base64]
url	Σ	0..1	url	Link to the local location where the document is kept Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
content:Binaerdaten	SΣ	0..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Access to the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
data		1..1	base64Binary	Document as binary data [Base64]
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
content:Verweis	SΣ	0..*	BackboneElement	Document referenced
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
attachment	SΣ	1..1	Attachment	Access to the document
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
contentType	SΣ	0..1	code	MIME type of the document content Binding: Mime Types (required): The mime type of an attachment. Any valid mime type is allowed. Example General: text/plain; charset=UTF-8, image/png
language	SΣ	0..1	code	Used language in the document Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding Example General: en-AU
url	Σ	1..1	url	Link to the local location where the document is kept Example General: http://www.acme.com/logo-small.png
size	Σ	0..1	unsignedInt	Number of bytes of content (if url provided)
hash	Σ	0..1	base64Binary	Hash of the data (sha-1, base64ed)
title	Σ	0..1	string	Label to display in place of the data Example General: Official Corporate Logo
creation	SΣ	0..1	dateTime	Date of the creation of the document
format	SΣ	0..1	Coding	Complex format specification Binding: MII VS Dokument Format Code (preferred)
context	SΣ	0..1	BackboneElement	Document creation context
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
encounter	S	0..*	Reference(Encounter | MII PR Fall Kontakt mit einer Gesundheitseinrichtung(2027.0.0-ballot))	Reference to FALL
event	S	0..*	CodeableConcept	Acts or procedures Binding: IHE XDS eventCodeList (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	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
period	SΣ	0..1	Period	Performance period
facilityType	S	0..1	CodeableConcept	Type of facility Binding: MII VS Dokument Einrichtungsart (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	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
practiceSetting	S	0..1	CodeableConcept	Clinical specialty Binding: MII VS Dokument Fachgebiet (required)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..*	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
sourcePatientInfo		0..1	Reference(Patient)	Patient demographics from source
related		0..*	Reference(Resource)	Related identifiers or resources
Documentation for this format

Terminology Bindings

Path	Status	Usage	ValueSet	Version	Source
DocumentReference.meta.​security	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.meta.​tag	Base	example	Common Tags	📍4.0.1	FHIR Std.
DocumentReference.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.status	Base	required	DocumentReferenceStatus	📍4.0.1	FHIR Std.
DocumentReference.docStatus	Base	required	CompositionStatus	📍4.0.1	FHIR Std.
DocumentReference.type	Base	preferred	Document Type Value Set	📍4.0.1	FHIR Std.
DocumentReference.type.​coding:KDL	Base	required	ValueSet Klinische Dokumentenklassen-Liste (Version 2025)	📦2025	dvmd.kdl.r4 v2025.0
DocumentReference.type.​coding:LNC	Base	required	Document Type Value Set	📦4.0.1	FHIR Std.
DocumentReference.type.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Typ	📦2027.0.0-ballot.2	This IG
DocumentReference.type.​coding:XDS	Base	required	IHE XDS typeCode	📦2020-02-07T07:55:58	de.ihe-d.terminology v3.0
DocumentReference.category	Base	example	Document Class Value Set	📍4.0.1	FHIR Std.
DocumentReference.category.​coding:LNC	Base	required	Document Class Value Set	📦4.0.1	FHIR Std.
DocumentReference.category.​coding:SCT	Base	required	MII VS Dokument SCT Dokument Kategorie	📦2027.0.0-ballot.2	This IG
DocumentReference.category.​coding:XDS	Base	required	IHE XDS classCode	📦2021-06-25T13:44:47	de.ihe-d.terminology v3.0
DocumentReference.relatesTo.​code	Base	required	DocumentRelationshipType	📍4.0.1	FHIR Std.
DocumentReference.securityLabel	Base	extensible	SecurityLabels	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.content:Binaerdaten.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:Binaerdaten.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:Binaerdaten.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.content:Verweis.​attachment.contentType	Base	required	MimeType	📍4.0.1	FHIR Std.
DocumentReference.content:Verweis.​attachment.language	Base	preferred	Common Languages	📍4.0.1	FHIR Std.
DocumentReference.content:Verweis.​format	Base	preferred	MII VS Dokument Format Code	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​event	Base	required	IHE XDS eventCodeList	📦2021-07-06T21:19:41	de.ihe-d.terminology v3.0
DocumentReference.context.​facilityType	Base	required	MII VS Dokument Einrichtungsart	📦2027.0.0-ballot.2	This IG
DocumentReference.context.​practiceSetting	Base	required	MII VS Dokument Fachgebiet	📦2027.0.0-ballot.2	This IG

Constraints

Id	Grade	Path(s)	Description	Expression
dom-2	error	DocumentReference	If the resource is contained in another resource, it SHALL NOT contain nested Resources	contained.contained.empty()
dom-3	error	DocumentReference	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource	contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated	contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	DocumentReference	If a resource is contained in another resource, it SHALL NOT have a security label	contained.meta.security.empty()
dom-6	best practice	DocumentReference	A resource should have narrative for robust management	text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children	hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both	extension.exists() != value.exists()
mii-iv-dokument-dokument-category	warning	DocumentReference.category	Empfehlung: Eine Kodierungen aus XDS SOLLTE in `category` vorhanden sein	coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDSclassCode').exists()
mii-iv-dokument-dokument-type	warning	DocumentReference.type	Empfehlung: Mindestens eine Kodierungen aus KDL oder XDS SOLLTE in `type` vorhanden sein	coding.where(system = 'http://dvmd.de/fhir/CodeSystem/kdl').exists() or coding.where(system = 'http://ihe-d.de/CodeSystems/IHEXDStypeCode').exists()