MII IG Modul Patho
2027.0.0-ballot - Germany

MII IG Modul Patho - Local Development build (v2027.0.0-ballot) built by the FHIR (HL7® FHIR® Standard) Build Tools. See the Directory of published versions

Ressourcenprofil: MII PR Patho Composition

Offizielle URL: https://www.medizininformatik-initiative.de/fhir/ext/modul-patho/StructureDefinition/mii-pr-patho-composition Version: 2027.0.0-ballot
Active Stand: 2026-09-14 Maschinenlesbarer Name: MII_PR_Patho_Composition

Dieses Profil erbt von Profile - ISiK - BerichtSubsysteme aus der Spezifikation ISiK - Stufe 5.

Das Profil MII PR Patho Composition fasst als Profil einer Composition Ressource mit speziellen Constraints für ClinicalDocuments die Ressourcen für einen kompletten, textzentrierten Pathologiebefundbericht mit den Eigenschaften eines klinischen Dokuments zusammen. Ein vollständiges Beispiel einer Composition mit Narrativen findet sich im Prostate Cancer Spec IG. Dieses Profil ist das erste Entry in einem Bundle des Bundle.type “document”; Aufbau und Signatur des Bundles sind im Profil MII PR Patho Bundle beschrieben. Neben dem Diagnostischen Report (patho-diagnostic-report) und einem oder mehreren zusätzlichen kompletten Reports (additional-diagnostic-report) können die Beobachtungsberichtabschnitte optional auch direkt als eigene Sections der Composition geführt werden (Makroskopie, Mikroskopie, Intraoperativ, Diagnostische Schlussfolgerung, Zusätzliche Beobachtung); jede dieser Sections referenziert denselben Grouper wie DiagnosticReport.result. Composition und DiagnosticReport können zusätzlich über die Extension composition-diagnosticReportReference bzw. die R5-Cross-Version-Extension DiagnosticReport.composition wechselseitig aufeinander verweisen. Alle diese Ergänzungen sind optional.

Usages:

You can also check for usages in the FHIR IG Statistics

Formale Ansichten des Profilinhalts

Beschreibung von Profilen, Differentials, Snapshots und deren Repräsentationen.

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant Zeitpunkt der letzten Änderung
.... 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 S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Identifikator
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type SΣ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... system SΣ 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
..... coding:sct SΣ 0..1 Coding SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 0..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
..... coding:sct SΣ 0..1 Coding SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... system Σ 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
... subject SΣ 1..1 Reference(Resource) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 1..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian SΣ 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event SΣ 1..* BackboneElement Ereignis
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... Slices for section SC 1..* BackboneElement Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..* Reference(Resource) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:patho-diagnostic-report SC 1..* BackboneElement Pathologie-Diagnostikbericht
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60567-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..* Reference(MII PR Patho Report) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:makroskopie SC 0..1 BackboneElement Makroskopie
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22634-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:mikroskopie SC 0..1 BackboneElement Mikroskopie
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22635-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:intraoperativ SC 0..1 BackboneElement Intraoperative Beurteilung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 83321-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:diagnostische-schlussfolgerung SC 0..1 BackboneElement Diagnostische Schlussfolgerung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:zusaetzliche-beobachtung SC 0..1 BackboneElement Zusaetzliche Beobachtung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100969-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📦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.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:content-validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:patho-diagnostic-report.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:makroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:mikroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:intraoperativ.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:diagnostische-schlussfolgerung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:zusaetzliche-beobachtung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

Diese Struktur ist abgeleitet von ISiKBerichtSubSysteme

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... meta
.... lastUpdated S 0..1 instant Zeitpunkt der letzten Änderung
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... text 1..1 Narrative Header-Informationen
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
.... type S 1..1 CodeableConcept Description of identifier
..... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
... status 1..1 code Status des Dokumentes
... type
.... Slices for coding Content/Rules for all slices
..... coding:KDL 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)
..... coding:XDS 0..1 Coding Code defined by a terminology system
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
..... coding:sct S 0..1 Coding SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
Required Pattern: At least the following
...... system S 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code S 0..1 code Symbol in syntax defined by the system
... category
.... Slices for coding Content/Rules for all slices
..... coding:IHE 0..1 Coding Code defined by a terminology system
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
..... coding:sct S 0..1 Coding SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... system 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
... encounter 1..1 Reference(Encounter) Aufenthaltsbezug
... author 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... mode 1..1 code personal | professional | legal | official
Fixed Value: legal
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... mode 1..1 code personal | professional | legal | official
Fixed Value: professional
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian S 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... code S 1..1 code replaces | transforms | signs | appends
.... Slices for target[x] 1..1 Identifier, Reference(Composition) Target of the relationship
Slice: Unordered, Open by type:$this
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event S 1..* BackboneElement Ereignis
... Slices for section 1..* BackboneElement Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
.... section:All Slices Content/Rules for all slices
..... code S 1..1 CodeableConcept Classification of section (recommended)
...... coding S 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
..... entry S 1..* Reference(Resource) A reference to data that supports this section
.... section:patho-diagnostic-report S 1..* BackboneElement Pathologie-Diagnostikbericht
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 60567-5
..... entry 1..* Reference(MII PR Patho Report) A reference to data that supports this section
.... section:makroskopie S 0..1 BackboneElement Makroskopie
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22634-0
..... entry 1..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
.... section:mikroskopie S 0..1 BackboneElement Mikroskopie
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22635-7
..... entry 1..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
.... section:intraoperativ S 0..1 BackboneElement Intraoperative Beurteilung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 83321-0
..... entry 1..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
.... section:diagnostische-schlussfolgerung S 0..1 BackboneElement Diagnostische Schlussfolgerung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22637-3
..... entry 1..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
.... section:zusaetzliche-beobachtung S 0..1 BackboneElement Zusaetzliche Beobachtung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 100969-5
..... entry 1..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.section.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 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 Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated SΣ 0..1 instant Zeitpunkt der letzten Änderung
.... 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
... text S 1..1 Narrative Header-Informationen
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Identifikator
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type SΣ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... 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

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... system SΣ 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
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 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)

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 Σ 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 ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
...... 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

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 Σ 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 Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
...... 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 SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)

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 0..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 0..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 SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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 Σ 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 Σ 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:IHE SΣ 0..1 Coding Code defined by a terminology system

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 Σ 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 Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
...... 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 SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... 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 Σ 0..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 Σ 0..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 1..1 Reference(Resource) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 1..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... 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.
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester: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
..... 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
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... 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.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... 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.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian SΣ 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... 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 S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event SΣ 1..* BackboneElement Ereignis
.... 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 Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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) A reference to data that supports this section
..... 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) Unterkapitel
.... section:patho-diagnostic-report SC 1..* BackboneElement Pathologie-Diagnostikbericht
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60567-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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 Patho Report) A reference to data that supports this section
..... 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) Unterkapitel
.... section:makroskopie SC 0..1 BackboneElement Makroskopie
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22634-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:mikroskopie SC 0..1 BackboneElement Mikroskopie
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22635-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:intraoperativ SC 0..1 BackboneElement Intraoperative Beurteilung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 83321-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:diagnostische-schlussfolgerung SC 0..1 BackboneElement Diagnostische Schlussfolgerung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:zusaetzliche-beobachtung SC 0..1 BackboneElement Zusaetzliche Beobachtung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100969-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section
..... 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) Unterkapitel

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.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📦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.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.subject.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
Composition.encounter.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
Composition.author.type Base extensible ResourceType 📦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.attester:legal.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:content-validator.​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.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
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:patho-diagnostic-report.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:patho-diagnostic-report.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:makroskopie.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:makroskopie.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:mikroskopie.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:mikroskopie.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:intraoperativ.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:intraoperativ.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:diagnostische-schlussfolgerung.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:zusaetzliche-beobachtung.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

Diese Struktur ist abgeleitet von ISiKBerichtSubSysteme

Summary

Mandatory: 10 elements(2 nested mandatory elements)
Must-Support: 28 elements
Fixed: 6 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.attester
  • The element 1 is sliced based on the value of Composition.relatesTo.target[x]
  • The element 1 is sliced based on the value of Composition.section

Schlüsselelemente-Ansicht

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 0..1 Meta Metadata about the resource
.... lastUpdated SΣ 0..1 instant Zeitpunkt der letzten Änderung
.... 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 S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Identifikator
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type SΣ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... coding Σ 0..* Coding Code defined by a terminology system

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
...... userSelected 0..1 boolean If this coding was chosen directly by the user
.... system SΣ 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
Binding: FHIRDocumentTypeCodes (preferred): Type of a composition.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://dvmd.de/fhir/CodeSystem/kdl
...... code ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
..... coding:XDS SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDStypeCode
...... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
..... coding:sct SΣ 0..1 Coding SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system SΣ 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code SΣ 0..1 code Symbol in syntax defined by the system
.... text SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
...... code Σ 1..1 code Symbol in syntax defined by the system
..... coding:IHE SΣ 0..1 Coding Code defined by a terminology system

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
...... display 0..1 string Representation defined by the system
...... userSelected 0..1 boolean If this coding was chosen directly by the user
...... system Σ 1..1 uri Identity of the terminology system
Fixed Value: http://ihe-d.de/CodeSystems/IHEXDSclassCode
...... code Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
..... coding:sct SΣ 0..1 Coding SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... system Σ 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
... subject SΣ 1..1 Reference(Resource) Patientenbezug
.... reference SΣC 1..1 string Patienten-Link
... encounter SΣ 1..1 Reference(Encounter) Aufenthaltsbezug
.... reference SΣC 1..1 string Encounter-Link
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester:All Slices Content/Rules for all slices
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: legal
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... mode 1..1 code personal | professional | legal | official
Binding: CompositionAttestationMode (required): The way in which a person authenticated a composition.
Fixed Value: professional
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian SΣ 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
.... code S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event SΣ 1..* BackboneElement Ereignis
.... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
... Slices for section SC 1..* BackboneElement Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..* Reference(Resource) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:patho-diagnostic-report SC 1..* BackboneElement Pathologie-Diagnostikbericht
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60567-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..* Reference(MII PR Patho Report) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:makroskopie SC 0..1 BackboneElement Makroskopie
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22634-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:mikroskopie SC 0..1 BackboneElement Mikroskopie
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22635-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:intraoperativ SC 0..1 BackboneElement Intraoperative Beurteilung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 83321-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:diagnostische-schlussfolgerung SC 0..1 BackboneElement Diagnostische Schlussfolgerung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel
.... section:zusaetzliche-beobachtung SC 0..1 BackboneElement Zusaetzliche Beobachtung
Constraints: cmp-1, cmp-2
..... modifierExtension ?!Σ 0..* Extension Extensions that cannot be ignored even if unrecognized
..... title S 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
Binding: DocumentSectionCodes (example): Classification of a section of a composition/document.
...... coding SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100969-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text SC 1..1 Narrative Narrativ
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
..... entry SC 1..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section
..... section SC 0..* See section (Composition) Unterkapitel

doco Documentation for this format

Terminology Bindings

Path Status Usage ValueSet Version Source
Composition.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📦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.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.attester.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:legal.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:content-validator.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.relatesTo.​code Base required DocumentRelationshipType 📍4.0.1 FHIR Std.
Composition.section.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:patho-diagnostic-report.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:makroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:mikroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:intraoperativ.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:diagnostische-schlussfolgerung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:zusaetzliche-beobachtung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG

Constraints

Id Grade Path(s) Description Expression
cmp-1 error Composition.section, Composition.section:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

Differential-Ansicht

Diese Struktur ist abgeleitet von ISiKBerichtSubSysteme

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... meta
.... lastUpdated S 0..1 instant Zeitpunkt der letzten Änderung
.... profile S 0..* canonical(StructureDefinition) Profiles this resource claims to conform to
... text 1..1 Narrative Header-Informationen
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
.... type S 1..1 CodeableConcept Description of identifier
..... coding 0..* Coding Code defined by a terminology system
Required Pattern: At least the following
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
... status 1..1 code Status des Dokumentes
... type
.... Slices for coding Content/Rules for all slices
..... coding:KDL 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)
..... coding:XDS 0..1 Coding Code defined by a terminology system
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
..... coding:sct S 0..1 Coding SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
Required Pattern: At least the following
...... system S 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
...... code S 0..1 code Symbol in syntax defined by the system
... category
.... Slices for coding Content/Rules for all slices
..... coding:IHE 0..1 Coding Code defined by a terminology system
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
..... coding:sct S 0..1 Coding SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... system 0..1 uri Identity of the terminology system
Fixed Value: http://snomed.info/sct
... encounter 1..1 Reference(Encounter) Aufenthaltsbezug
... author 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... mode 1..1 code personal | professional | legal | official
Fixed Value: legal
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... mode 1..1 code personal | professional | legal | official
Fixed Value: professional
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian S 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... code S 1..1 code replaces | transforms | signs | appends
.... Slices for target[x] 1..1 Identifier, Reference(Composition) Target of the relationship
Slice: Unordered, Open by type:$this
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event S 1..* BackboneElement Ereignis
... Slices for section 1..* BackboneElement Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
.... section:All Slices Content/Rules for all slices
..... code S 1..1 CodeableConcept Classification of section (recommended)
...... coding S 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
..... entry S 1..* Reference(Resource) A reference to data that supports this section
.... section:patho-diagnostic-report S 1..* BackboneElement Pathologie-Diagnostikbericht
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 60567-5
..... entry 1..* Reference(MII PR Patho Report) A reference to data that supports this section
.... section:makroskopie S 0..1 BackboneElement Makroskopie
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22634-0
..... entry 1..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
.... section:mikroskopie S 0..1 BackboneElement Mikroskopie
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22635-7
..... entry 1..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
.... section:intraoperativ S 0..1 BackboneElement Intraoperative Beurteilung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 83321-0
..... entry 1..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
.... section:diagnostische-schlussfolgerung S 0..1 BackboneElement Diagnostische Schlussfolgerung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 22637-3
..... entry 1..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
.... section:zusaetzliche-beobachtung S 0..1 BackboneElement Zusaetzliche Beobachtung
..... code
...... coding 1..* Coding Code defined by a terminology system
Required Pattern: At least the following
....... 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: 100969-5
..... entry 1..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section

doco Documentation for this format

Terminology Bindings (Differential)

Path Status Usage ValueSet Version Source
Composition.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.section.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG

Snapshot-AnsichtView

NameFlagsCard.TypeDescription & Constraints    Filter: Filtersdoco
.. Composition 0..* ISiKBerichtSubSysteme A set of resources composed into a single coherent clinical statement with clinical attestation
... id SΣ 0..1 id serverseitige, interne ID des Datensatzes
... meta Σ 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 Eindeutiger Name der serverseitigen Version des Datensatzes
.... lastUpdated SΣ 0..1 instant Zeitpunkt der letzten Änderung
.... 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
... text S 1..1 Narrative Header-Informationen
This profile does not constrain the narrative in regard to content, language, or traceability to data elements
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... status S 1..1 code generated | extensions | additional | empty
Binding: NarrativeStatus (required): The status of a resource narrative.
Fixed Value: extensions
.... div SC 1..1 xhtml Limited xhtml content
Constraints: txt-1, txt-2
... contained 0..* Resource Contained, inline Resources
... Slices for extension 0..* Extension Extension
Slice: Unordered, Open by value:url
.... extension:document-version S 0..1 string Dokumentversion
URL: http://hl7.org/fhir/StructureDefinition/composition-clinicaldocument-versionNumber
.... extension:diagnosticReport S 0..1 Reference(DiagnosticReport) Diagnostikbericht
URL: http://hl7.eu/fhir/extensions/StructureDefinition/composition-diagnosticReportReference
... modifierExtension ?! 0..* Extension Extensions that cannot be ignored
... identifier SΣ 1..1 Identifier Identifikator
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... use ?!Σ 0..1 code usual | official | temp | secondary | old (If known)
Binding: IdentifierUse (required): Identifies the purpose for this identifier, if known .
.... type SΣ 1..1 CodeableConcept Description of identifier
Binding: Identifier Type Codes (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose.
..... 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

Required Pattern: At least the following
...... id 0..1 string Unique id for inter-element referencing
...... extension 0..* Extension Additional content defined by implementations
...... system 1..1 uri Identity of the terminology system
Fixed Value: http://terminology.hl7.org/CodeSystem/v2-0203
...... version 0..1 string Version of the system - if relevant
...... code 1..1 code Symbol in syntax defined by the system
Fixed Value: ACSN
...... display 1..1 string Representation defined by the system
Fixed Value: Accession ID
...... userSelected 0..1 boolean If this coding was chosen directly by the user
..... text Σ 0..1 string Plain text representation of the concept
.... system SΣ 0..1 uri Namensraum des Identifiers
Example General: http://www.acme.com/identifiers/patient
.... value SΣ 0..1 string The value that is unique
Example General: 123456
.... period Σ 0..1 Period Time period when id is/was valid for use
.... assigner Σ 0..1 Reference(Organization) Organization that issued id (may be just text)
... status ?!SΣ 1..1 code Status des Dokumentes
Binding: CompositionStatus (required): The workflow/clinical status of the composition.
Fixed Value: final
... type SΣ 1..1 CodeableConcept Dokumenttyp
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 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:KDL SΣ 0..1 Coding Code defined by a terminology system
Binding: MII VS Patho Composition Type KDL (extensible)

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 Σ 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 ΣC 1..1 code Symbol in syntax defined by the system
Constraints: kdl-1
...... 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

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 Σ 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 Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: PATH
...... 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 SNOMED CT Typ
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)

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 0..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 0..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 SΣ 0..1 string Dokumenttyp (Freitext)
... category SΣ 0..* CodeableConcept Dokument-Kategorie
Binding: DocumentClassValueSet (example): High-level kind of a clinical document at a macro level.
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... Slices for coding SΣ 0..* Coding Code defined by a terminology system
Slice: Unordered, Open by pattern:$this
..... coding:LOINC SΣ 0..1 Coding Code defined by a terminology system

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 Σ 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 Σ 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:IHE SΣ 0..1 Coding Code defined by a terminology system

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 Σ 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 Σ 1..1 code Symbol in syntax defined by the system
Fixed Value: BEF
...... 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 SNOMED CT Kategorie
Binding: MII VS Patho Composition Type [Snomed CT] (extensible)
...... 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 Σ 0..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 Σ 0..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 1..1 Reference(Resource) Patientenbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Patienten-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... encounter SΣ 1..1 Reference(Encounter) Aufenthaltsbezug
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference SΣC 1..1 string Encounter-Link
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display Σ 0..1 string Text alternative for the resource
... date SΣ 1..1 dateTime Dokumentendatum
... author SΣ 1..* Reference(ISiKPersonImGesundheitsberuf | Organization) Author can only be of type Practitioner or Organization
.... id 0..1 string Unique id for inter-element referencing
.... extension 0..* Extension Additional content defined by implementations
Slice: Unordered, Open by value:url
.... reference ΣC 0..1 string Literal reference, Relative, internal or absolute URL
.... type Σ 0..1 uri Type the reference refers to (e.g. "Patient")
Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
.... identifier Σ 0..1 Identifier Logical reference, when literal reference is not known
.... display SΣ 1..1 string Bezeichnung des Verfassers (Freitext)
... title SΣ 1..1 string Dokumentenbezeichnung
... 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.
... Slices for attester S 1..* BackboneElement Bestätiger
Slice: Unordered, Open by value:$this.mode
.... attester: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
..... 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
.... attester:legal S 1..* BackboneElement Rechtlicher Bestätiger
..... 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.
Fixed Value: legal
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(Practitioner | Organization) Partei
.... attester:content-validator S 0..* BackboneElement Inhaltssprüfer
..... 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.
Fixed Value: professional
..... time 0..1 dateTime When the composition was attested
..... party S 1..1 Reference(Practitioner | Organization) Partei
... custodian SΣ 1..1 Reference(Organization) Verwalter
... relatesTo S 0..* BackboneElement Bezieht sich auf
.... 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 S 1..1 code replaces | transforms | signs | appends
Binding: DocumentRelationshipType (required): The type of relationship between documents.
.... Slices for target[x] 1..1 Target of the relationship
Slice: Unordered, Open by type:$this
..... targetIdentifier Identifier
..... targetReference Reference(Composition)
..... target[x]:targetReference S 0..1 Reference(Composition) Target of the relationship
... event SΣ 1..* BackboneElement Ereignis
.... 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 Kapitel
Slice: Unordered, Open by pattern:$this.code.coding
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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) A reference to data that supports this section
..... 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) Unterkapitel
.... section:patho-diagnostic-report SC 1..* BackboneElement Pathologie-Diagnostikbericht
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 60567-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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 Patho Report) A reference to data that supports this section
..... 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) Unterkapitel
.... section:makroskopie SC 0..1 BackboneElement Makroskopie
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22634-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Macroscopic Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:mikroskopie SC 0..1 BackboneElement Mikroskopie
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22635-7
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Microscopic Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:intraoperativ SC 0..1 BackboneElement Intraoperative Beurteilung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 83321-0
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Intraoperative Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:diagnostische-schlussfolgerung SC 0..1 BackboneElement Diagnostische Schlussfolgerung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 22637-3
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Diagnostic Conclusion Grouper) A reference to data that supports this section
..... 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) Unterkapitel
.... section:zusaetzliche-beobachtung SC 0..1 BackboneElement Zusaetzliche Beobachtung
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 1..1 string Kapitelbezeichnung
..... code S 1..1 CodeableConcept Classification of section (recommended)
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 SΣ 1..* Coding Code defined by a terminology system
Binding: MII VS Patho All [LOINC] (required)

Required Pattern: At least the following
....... id 0..1 string Unique id for inter-element referencing
....... extension 0..* Extension Additional content defined by implementations
....... system 1..1 uri Identity of the terminology system
Fixed Value: http://loinc.org
....... version 0..1 string Version of the system - if relevant
....... code 1..1 code Symbol in syntax defined by the system
Fixed Value: 100969-5
....... display 0..1 string Representation defined by the system
....... userSelected 0..1 boolean If this coding was chosen directly by the user
...... text Σ 0..1 string Plain text representation of the concept
..... author 0..* Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) Who and/or what authored the section
..... focus 0..1 Reference(Resource) Who/what the section is about, when it is not about the subject of composition
..... text SC 1..1 Narrative Narrativ
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..1 Reference(MII PR Patho Additional Specified Grouper) A reference to data that supports this section
..... 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) Unterkapitel

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.text.status Base required NarrativeStatus 📍4.0.1 FHIR Std.
Composition.identifier.​use Base required IdentifierUse 📍4.0.1 FHIR Std.
Composition.identifier.​type Base extensible IdentifierType 📦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.type.coding:KDL Base extensible MII VS Patho Composition Type KDL 📦2027.0.0-ballot This IG
Composition.type.coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.category Base example Document Class Value Set 📦4.0.1 FHIR Std.
Composition.category.​coding:sct Base extensible MII VS Patho Composition Type [Snomed CT] 📦2027.0.0-ballot This IG
Composition.subject.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
Composition.encounter.​type Base extensible ResourceType 📦4.0.1 FHIR Std.
Composition.author.type Base extensible ResourceType 📦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.attester:legal.​mode Base required CompositionAttestationMode 📍4.0.1 FHIR Std.
Composition.attester:content-validator.​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.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
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:patho-diagnostic-report.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:patho-diagnostic-report.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:patho-diagnostic-report.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:makroskopie.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:makroskopie.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:makroskopie.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:mikroskopie.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:mikroskopie.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:mikroskopie.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:intraoperativ.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:intraoperativ.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:intraoperativ.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:diagnostische-schlussfolgerung.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:diagnostische-schlussfolgerung.​emptyReason Base preferred List Empty Reasons 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code Base example Document Section Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​code.coding Base required MII VS Patho All [LOINC] 📦2027.0.0-ballot This IG
Composition.section:zusaetzliche-beobachtung.​mode Base required ListMode 📍4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​orderedBy Base preferred List Order Codes 📦4.0.1 FHIR Std.
Composition.section:zusaetzliche-beobachtung.​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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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:patho-diagnostic-report, Composition.section:makroskopie, Composition.section:mikroskopie, Composition.section:intraoperativ, Composition.section:diagnostische-schlussfolgerung, Composition.section:zusaetzliche-beobachtung 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()
kdl-1 warning Composition.type.coding:KDL.code KDL-Code ungültig matches('^[A-Z]{2}[0-9]{6}$')
txt-1 error Composition.text.div The narrative SHALL contain only the basic html formatting elements and attributes described in chapters 7-11 (except section 4 of chapter 9) and 15 of the HTML 4.0 standard, <a> elements (either name or href), images and internally contained style attributes htmlChecks()
txt-2 error Composition.text.div The narrative SHALL have some non-whitespace content htmlChecks()

Diese Struktur ist abgeleitet von ISiKBerichtSubSysteme

Summary

Mandatory: 10 elements(2 nested mandatory elements)
Must-Support: 28 elements
Fixed: 6 elements

Structures

This structure refers to these other structures:

Extensions

This structure refers to these extensions:

Slices

This structure defines the following Slices:

  • The element 1 is sliced based on the value of Composition.attester
  • The element 1 is sliced based on the value of Composition.relatesTo.target[x]
  • The element 1 is sliced based on the value of Composition.section

 

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