MII IG Dokument
2027.0.0-ballot.2 -
MII IG Dokument
2027.0.0-ballot.2 -
This page is part of the MII IG Dokument (v2027.0.0-ballot.2: 2027 Ballot 3) based on FHIR (HL7® FHIR® Standard) R4. This is the current published version. For a full list of available versions, see the Directory of published versions
Die logischen Datenmodelle des Moduls Dokument beschreiben den fachlichen Datensatz unabhängig von der konkreten FHIR-Repräsentation.
Die offiziell beschlossene Version des Informationsmodells befinden sich auf ART DECOR. Zur Vereinheitlichung der Repräsentation wurde das Informationsmodell zusätzlich als FHIR Logical Model abgebildet:
Das folgende Verzeichnis listet jedes Element des logischen Modells mit Pfad und Beschreibung.
Guidance on how to interpret the contents of this table can be foundhere
| 0. mii-lm-dokument | |
| Definition | MII Logical Model KDS-Modul Dokument |
| Short | MII LM Dokument |
| Control | 0..* This element is affected by the following invariants: ele-1 |
| Is Modifier | false |
| Logical Model | Instances of this logical model are not marked to be the target of a Reference |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 2. mii-lm-dokument.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 4. mii-lm-dokument.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on mii-lm-dokument.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 6. mii-lm-dokument.Dokument | |
| Definition | Klinisches Dokument inkl. Metadaten, Inhalt, Erzeugungskontext und Beziehungen |
| Short | Dokument |
| Control | 1..1 |
| Type | BackboneElement |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 8. mii-lm-dokument.Dokument.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 10. mii-lm-dokument.Dokument.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on mii-lm-dokument.Dokument.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 12. mii-lm-dokument.Dokument.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| 14. mii-lm-dokument.Dokument.Masteridentifikator | |
| Definition | Versionsspezifische eindeutige Kennung, die dem Dokument durch die Dokumentenquelle zugewiesen wurde |
| Short | Versionsspezifische Kennung |
| Control | 0..1 |
| Type | Identifier |
| 16. mii-lm-dokument.Dokument.Businessidentifikator | |
| Definition | Andere versionsunabhängige Kennung, die dem Dokument (z.B. durch weitere dokumentenverarbeitende Systeme) zugewiesen wurde |
| Short | Versionsunabhängige Kennung |
| Control | 0..1 |
| Type | Identifier |
| 18. mii-lm-dokument.Dokument.Dokumentenreferenzstatus | |
| Definition | Status dieser Dokumentenreferenz (aktuell, überholt oder irrtümlich eingegeben) |
| Short | Status der Dokumentenreferenz |
| Control | 1..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 20. mii-lm-dokument.Dokument.Dokumentenstatus | |
| Definition | Status des zugrunde liegenden Dokuments (vorläufig, final, geändert oder irrtümlich eingegeben) |
| Short | Status des Dokuments |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 22. mii-lm-dokument.Dokument.Dokumententyp | |
| Definition | Art des Dokuments auf das verwiesen wird (z.B. Anamnese und Untersuchung, Entlassungsbericht, Verlaufsbericht) |
| Short | Art des Dokuments |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 24. mii-lm-dokument.Dokument.Dokumentenkategorie | |
| Definition | Übergeordnete Kategorie des Dokuments auf das verwiesen wird (z.B. Arztberichte oder Arztdokumentation) |
| Short | Kategorien des Dokuments |
| Control | 0..* |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 26. mii-lm-dokument.Dokument.Patient | |
| Definition | Patient auf den sich das verwiesene Dokument bezieht |
| Short | Verweis auf Patient |
| Control | 0..1 |
| Type | Identifier |
| 28. mii-lm-dokument.Dokument.Beschreibung | |
| Definition | Menschenlesbare Beschreibung zum verwiesenen Dokuments |
| Short | Beschreibung des Dokuments |
| Control | 0..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 30. mii-lm-dokument.Dokument.Sicherheitsstufe | |
| Definition | Grad der Vertraulichkeit/Sicherheit des verwiesenen Dokuments (z. B. uneingeschränkt, gering, mittel, normal oder eingeschränkt) |
| Short | Vertraulichkeit des Dokuments |
| Control | 0..* |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 32. mii-lm-dokument.Dokument.Dokumentenbeziehung | |
| Definition | Beziehungen des verwiesenen Dokuments zu anderen Dokumenten |
| Short | Beziehung des Dokuments |
| Control | 0..* |
| Type | BackboneElement |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 34. mii-lm-dokument.Dokument.Dokumentenbeziehung.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 36. mii-lm-dokument.Dokument.Dokumentenbeziehung.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on mii-lm-dokument.Dokument.Dokumentenbeziehung.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 38. mii-lm-dokument.Dokument.Dokumentenbeziehung.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| 40. mii-lm-dokument.Dokument.Dokumentenbeziehung.Beziehungstyp | |
| Definition | Beziehung zu anderen Dokumenten |
| Short | Art der Beziehung |
| Control | 1..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 42. mii-lm-dokument.Dokument.Dokumentenbeziehung.Beziehungsreferenz | |
| Definition | Ziel der Dokumentenbeziehung |
| Short | Verweis auf Dokument |
| Control | 1..1 |
| Type | Identifier |
| 44. mii-lm-dokument.Dokument.Anhang | |
| Definition | Dokument (Base64-kodierte Daten) oder Verweis (URL) mit relevanten Metadaten zum Anhang |
| Short | Inhalt des Dokuments |
| Control | 1..* |
| Type | BackboneElement |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 46. mii-lm-dokument.Dokument.Anhang.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 48. mii-lm-dokument.Dokument.Anhang.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on mii-lm-dokument.Dokument.Anhang.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 50. mii-lm-dokument.Dokument.Anhang.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| 52. mii-lm-dokument.Dokument.Anhang.Sprache | |
| Definition | Verwendete Sprache in dem Dokument |
| Short | Verfassungssprache des Inhalts |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 54. mii-lm-dokument.Dokument.Anhang.Erstellungsdatum | |
| Definition | Datum der Erstellung des Dokumentes |
| Short | Erstellungsdatum des Inhalts |
| Control | 0..1 |
| Type | dateTime |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 56. mii-lm-dokument.Dokument.Anhang.Daten | |
| Definition | Dokument als Binärdaten |
| Short | Binärdaten zum Inhalt |
| Control | 0..1 |
| Type | base64Binary |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 58. mii-lm-dokument.Dokument.Anhang.DokumentenUrl | |
| Definition | Verweis auf den (lokalen) Ablageort des Dokuments |
| Short | URL zum Inhalt |
| Control | 0..1 |
| Type | string |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 60. mii-lm-dokument.Dokument.Anhang.Dokumentenformat | |
| Definition | MIME-Typ des Dokumenteninhalts |
| Short | MIME-Typ zum Inhalt |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 62. mii-lm-dokument.Dokument.Kontext | |
| Definition | Klinischer Kontext, in welchem das Dokument erzeugt wurde |
| Short | Erzeugungskontext des Dokuments |
| Control | 0..1 |
| Type | BackboneElement |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count())) |
| 64. mii-lm-dokument.Dokument.Kontext.id | |
| Definition | Unique id for the element within a resource (for internal references). This may be any string value that does not contain spaces. |
| Short | Unique id for inter-element referencing |
| Control | 0..1 |
| Type | string |
| Is Modifier | false |
| XML Format | In the XML format, this property is represented as an attribute. |
| Summary | false |
| 66. mii-lm-dokument.Dokument.Kontext.extension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. |
| Short | Additional content defined by implementations |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | false |
| Summary | false |
| Alternate Names | extensions, user content |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| Slicing | This element introduces a set of slices on mii-lm-dokument.Dokument.Kontext.extension. The slices areUnordered and Open, and can be differentiated using the following discriminators: |
| 68. mii-lm-dokument.Dokument.Kontext.modifierExtension | |
| Definition | May be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). |
| Short | Extensions that cannot be ignored even if unrecognized |
| Comments | There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. |
| Control | 0..* |
| Type | Extension |
| Is Modifier | true because Modifier extensions are expected to modify the meaning or interpretation of the element that contains them |
| Summary | true |
| Requirements | Modifier extensions allow for extensions that cannot be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the definition of modifier extensions. |
| Alternate Names | extensions, user content, modifiers |
| Invariants | ele-1: All FHIR elements must have a @value or children (hasValue() or (children().count() > id.count()))ext-1: Must have either extensions or value[x], not both ( extension.exists() != value.exists()) |
| 70. mii-lm-dokument.Dokument.Kontext.Gesundheitseinrichtungskontakt | |
| Definition | Kontakt zur Gesundheitseinrichtung oder die Art der Versorgung, die mit dem Dokumenteninhalt assoziiert ist |
| Short | Verweis auf Einrichtungskontakt |
| Control | 0..* |
| Type | Identifier |
| 72. mii-lm-dokument.Dokument.Kontext.Vorgang | |
| Definition | Handlungen oder Prozeduren, die im Kontext dokumentiert wurden |
| Short | Dokumentierter Vorgang |
| Control | 0..* |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 74. mii-lm-dokument.Dokument.Kontext.Fachgebiet | |
| Definition | Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde |
| Short | Klinisches Fachgebiet zum Vorgang |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
| 76. mii-lm-dokument.Dokument.Kontext.Dokumentationszeitraum | |
| Definition | Zeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde |
| Short | Durchführungszeitraum zum Vorgang |
| Control | 0..1 |
| Type | Period |
| 78. mii-lm-dokument.Dokument.Kontext.Einrichtungsart | |
| Definition | Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte |
| Short | Art der Einrichtung zum Vorgang |
| Control | 0..1 |
| Type | code |
| Primitive Value | This primitive element may be present, or absent, or replaced by an extension |
Es ist zu beachten, dass das Logical Model rein auf die Abbildung der Datenelemente und deren Beschreibung abzielt. Verwendete Datentypen und Kardinalitäten sind nicht als verpflichtend anzusehen. Dies wird abschließend durch die FHIR-Profile festgelegt. Für jedes Element innerhalb des Logical Models existiert ein 1:1 Mapping auf ein Element einer konkreten FHIR Ressource.
Der IG-Publisher rendert dieses Element-zu-Ressource-Mapping auf der Artefaktseite des Logical Models nicht (der Reiter „Mappings“ bleibt dort leer). Die folgende Tabelle listet es deshalb hier auf.
| Logischer Datensatz | FHIR-Mapping | Beschreibung |
| Dokument | DocumentReference | Klinisches Dokument inkl. Metadaten, Inhalt, Erzeugungskontext und Beziehungen |
| Dokument.Masteridentifikator | DocumentReference.masterIdentifier | Versionsspezifische eindeutige Kennung, die dem Dokument durch die Dokumentenquelle zugewiesen wurde |
| Dokument.Businessidentifikator | DocumentReference.identifier | Andere versionsunabhängige Kennung, die dem Dokument (z.B. durch weitere dokumentenverarbeitende Systeme) zugewiesen wurde |
| Dokument.Dokumentenreferenzstatus | DocumentReference.status | Status dieser Dokumentenreferenz (aktuell, überholt oder irrtümlich eingegeben) |
| Dokument.Dokumentenstatus | DocumentReference.docStatus | Status des zugrunde liegenden Dokuments (vorläufig, final, geändert oder irrtümlich eingegeben) |
| Dokument.Dokumententyp | DocumentReference.type | Art des Dokuments auf das verwiesen wird (z.B. Anamnese und Untersuchung, Entlassungsbericht, Verlaufsbericht) |
| Dokument.Dokumentenkategorie | DocumentReference.category | Übergeordnete Kategorie des Dokuments auf das verwiesen wird (z.B. Arztberichte oder Arztdokumentation) |
| Dokument.Patient | DocumentReference.subject | Patient auf den sich das verwiesene Dokument bezieht |
| Dokument.Beschreibung | DocumentReference.description | Menschenlesbare Beschreibung zum verwiesenen Dokuments |
| Dokument.Sicherheitsstufe | DocumentReference.securityLabel | Grad der Vertraulichkeit/Sicherheit des verwiesenen Dokuments (z. B. uneingeschränkt, gering, mittel, normal oder eingeschränkt) |
| Dokument.Dokumentenbeziehung | DocumentReference.relatesTo | Beziehungen des verwiesenen Dokuments zu anderen Dokumenten |
| Dokument.Dokumentenbeziehung.Beziehungstyp | DocumentReference.relatesTo.code | Beziehung zu anderen Dokumenten |
| Dokument.Dokumentenbeziehung.Beziehungsreferenz | DocumentReference.relatesTo.target | Ziel der Dokumentenbeziehung |
| Dokument.Anhang | DocumentReference.content | Dokument (Base64-kodierte Daten) oder Verweis (URL) mit relevanten Metadaten zum Anhang |
| Dokument.Anhang.Sprache | DocumentReference.attachment.language | Verwendete Sprache in dem Dokument |
| Dokument.Anhang.Erstellungsdatum | DocumentReference.attachment.creation | Datum der Erstellung des Dokumentes |
| Dokument.Anhang.Daten | DocumentReference.attachment.data | Dokument als Binärdaten |
| Dokument.Anhang.DokumentenUrl | DocumentReference.attachment.url | Verweis auf den (lokalen) Ablageort des Dokuments |
| Dokument.Anhang.Dokumentenformat | DocumentReference.attachment.contentType | MIME-Typ des Dokumenteninhalts |
| Dokument.Kontext | DocumentReference.context | Klinischer Kontext, in welchem das Dokument erzeugt wurde |
| Dokument.Kontext.Gesundheitseinrichtungskontakt | DocumentReference.context.encounter | Kontakt zur Gesundheitseinrichtung oder die Art der Versorgung, die mit dem Dokumenteninhalt assoziiert ist |
| Dokument.Kontext.Vorgang | DocumentReference.context.event | Handlungen oder Prozeduren, die im Kontext dokumentiert wurden |
| Dokument.Kontext.Fachgebiet | DocumentReference.context.practiceSetting | Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde |
| Dokument.Kontext.Dokumentationszeitraum | DocumentReference.context.period | Zeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde |
| Dokument.Kontext.Einrichtungsart | DocumentReference.context.facilityType | Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte |