| Left: | ISiKBerichtSubSysteme (https://gematik.de/fhir/isik/StructureDefinition/ISiKBerichtSubSysteme) |
| Right: | Composition (HDR) (http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr) |
| Error | StructureDefinition.url | Values for url differ: 'https://gematik.de/fhir/isik/StructureDefinition/ISiKBerichtSubSysteme' vs 'http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr' |
| Error | StructureDefinition.version | Values for version differ: '5.0.0' vs '0.1.0-ballot' |
| Information | StructureDefinition.name | Values for name differ: 'ISiKBerichtSubSysteme' vs 'CompositionEuHdr' |
| Information | StructureDefinition.status | Values for status differ: 'active' vs 'draft' |
| Information | StructureDefinition.date | Values for date differ: '2025-06-26' vs '2025-06-03T12:48:49+02:00' |
| Information | StructureDefinition.publisher | Values for publisher differ: 'gematik GmbH' vs 'HL7 Europe' |
| Information | StructureDefinition.jurisdiction | Added the item 'http://unstats.un.org/unsd/methods/m49/m49.htm#150' |
| Information | StructureDefinition.short | Values for short differ: 'A set of resources composed into a single coherent clinical statement with clinical attestation' vs 'Hospital Discharge Report composition' |
| Information | StructureDefinition.definition | Values for definition differ: 'A set of healthcare-related information that is assembled together into a single logical package that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. A Composition defines the structure and narrative content necessary for a document. However, a Composition alone does not constitute a document. Rather, the Composition must be the first entry in a Bundle where Bundle.type=document, and any other resources referenced from Composition must be included as subsequent entries in the Bundle (for example Patient, Practitioner, Encounter, etc.).' vs 'Hospital Discharge Report composition. A composition is a set of healthcare-related information that is assembled together into a single logical document that provides a single coherent statement of meaning, establishes its own context and that has clinical attestation with regard to who is making the statement. While a Composition defines the structure, it does not actually contain the content: rather the full content of a document is contained in a Bundle, of which the Composition is the first resource contained.' |
| Information | StructureDefinition.short | Values for short differ: 'Narrativ' vs 'Text summary of the resource, for human interpretation' |
| Information | StructureDefinition.comment | Values for comment differ: 'HTML-Repräsentation des Dokumenten-Headers. Bitte Hinweise unter [Document Presentation](https://hl7.org/fhir/documents.html#presentation) beachten. Der DokumentenHeader muss mindestens die folgenden Informationen enthalten: * `Composition.subject:Patient.name.family` * `Composition.subject:Patient.birthDate` * `Composition.subject:Patient.identifier:pid` * `Composition.status` * `Composition.type.text` * `Composition.date` * `Composition.title` * `Composition.author.display`' vs 'Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a 'text blob' or where text is additionally entered raw or narrated and encoded information is added later.' |
| Warning | Composition.text | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Composition.text | Element minimum cardinalities differ: '1' vs '0' |
| Information | StructureDefinition.short | Values for short differ: 'Additional content defined by implementations' vs 'Extension' |
| Information | StructureDefinition.definition | Values for definition differ: 'May be used to represent additional information that is not part of the basic definition of the resource. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension.' vs 'An Extension' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'Eindeutige Dokumenten-ID' vs 'HDR business identifier' |
| Information | StructureDefinition.comment | Values for comment differ: 'Eine vom erzeugenden Subsystem vergebene, eindeutige DokumentenID. Wenn es sich bei dem verwendeten Identifier um eine OID oder UUID handelt, so ist hier der Wert `urn:ietf:rfc:3986` anzugeben und in `Identifier.value` das jeweilige Präfix `urn:uuid:` bzw. `urn:oid:` zu verwenden. Beispiel: ```xml <identifier> <system value='urn:ietf:rfc:3986'> <value value='urn:oid:2.16.840.1.113883.6.96'> </identifier> ```' vs 'Similar to ClinicalDocument/setId in CDA. See discussion in resource definition for how these relate.' |
| Warning | Composition.identifier | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Composition.identifier | Element minimum cardinalities differ: '1' vs '0' |
| Information | StructureDefinition.short | Values for short differ: 'Status des Dokumentes' vs 'HDR status' |
| Information | StructureDefinition.comment | Values for comment differ: 'Im Kontext diese Moduls ist nur der Austausch finaler Berichte vorgesehen. Ein Mechanismus zur Änderung oder Ersetzung bereits übermittelter Daten ist derzeit nicht spezifiziert. Hier ist stets der Wert `final` anzugeben.' vs 'If a composition is marked as withdrawn, the compositions/documents in the series, or data from the composition or document series, should never be displayed to a user without being clearly marked as untrustworthy. The flag 'entered-in-error' is why this element is labeled as a modifier of other elements. Some reporting work flows require that the original narrative of a final document never be altered; instead, only new narrative can be added. The composition resource has no explicit status for explicitly noting whether this business rule is in effect. This would be handled by an extension if required.' |
| Warning | Composition.status | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Dokumenttyp' vs 'Kind of composition ('Hospital Discharge Report')' |
| Information | StructureDefinition.definition | Values for definition differ: 'Specifies the particular kind of composition (e.g. History and Physical, Discharge Summary, Progress Note). This usually equates to the purpose of making the composition.' vs 'Specifies that this composition refer to a Hospital Discharge Report' |
| Information | StructureDefinition.comment | Values for comment differ: 'Begründung zu Must Support: Der Dokumenttyp ist für die Identifikation des Berichtes und die Zuordnung zu einem Subsystem für die weitere Verarbeitung erforderlich. *Hinweis für Implementierer:* Der zu übermittelnde Bericht repräsentiert eine Zusammenfassung der strukturierten Daten aus dem Subsystem. Das Dokument KANN z.B. mittels KDL oder IHE-D-XDS-Typecodes klassifiziert werden. Es KANN derzeit jedoch auch eine rein textuelle Beschreibung des Dokumenttyps angegeben werden. Während KDL-Codes eine feingranulare Dokumentenklassifikation für die gezielte Suche nach medizinischen und Administrativen Dokumenten ermöglichen, sind IHE-XDS-Type-Codes für den einrichtungsübergreifenden Dokumentenaustausch maßgeblich. Der XDS-Type-Code kann mit Hilfe der bereitgestellten [ConceptMaps](https://simplifier.net/kdl/~resources?category=ConceptMap) aus dem KDL-Code ermittelt werden. Weitere Typisierungen (z.B. nach SNOMED oder LOINC) sind uneingeschränkt erlaubt. [Konsens der Arbeitsgruppe vom 18.02.2022]. Im Falle, dass der Code 'UNK' entsprechend der ConceptMap verwendet werden soll, MUSS das System 'http://terminology.hl7.org/CodeSystem/v3-NullFlavor' verwendet werden.' vs 'For Composition type, LOINC is ubiquitous and strongly endorsed by HL7. Most implementation guides will require a specific LOINC code, or use LOINC as an extensible binding.' |
| Warning | Composition.type | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Dokument-Kategorie' vs 'Categorization of Composition' |
| Information | StructureDefinition.comment | Values for comment differ: 'Begründung zu Must Support: Die Klassifizierung kann zur Strukturierung der Berichte genutzt werden, in dem Fall, dass das Narrative des Berichts dem Benutzer angezeigt wird. Das Dokument KANN z.B. mittels LOINC oder IHE-D-XDS-Classcodes klassifiziert werden.' vs 'This is a metadata field from [XDS/MHD](http://wiki.ihe.net/index.php?title=Mobile_access_to_Health_Documents_(MHD)).' |
| Warning | Composition.category | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Patientenbezug' vs 'Who and/or what the composition is about' |
| Information | StructureDefinition.definition | Values for definition differ: 'Who or what the composition is about. The composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure).' vs 'Who or what the composition is about. In general a composition can be about a person, (patient or healthcare practitioner), a device (e.g. a machine) or even a group of subjects (such as a document about a herd of livestock, or a set of patients that share a common exposure). For the hdr the subject is always the patient.' |
| Warning | Composition.subject | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Aufenthaltsbezug' vs 'Context of the Composition' |
| Warning | Composition.encounter | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Dokumentendatum' vs 'HDR date' |
| Information | StructureDefinition.comment | Values for comment differ: 'Datum der letzten Änderung des Dokumentes' vs 'The Last Modified Date on the composition may be after the date of the document was attested without being changed.' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](bundle-definitions.html#Bundle.timestamp) is the date of packaging.' vs 'dateTime is used for tracking, organizing versions and searching. Note that this is the time of *authoring*. When packaged in a document, [Bundle.timestamp](http://hl7.org/fhir/R4/bundle-definitions.html#Bundle.timestamp) is the date of packaging.' |
| Warning | Composition.date | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.short | Values for short differ: 'Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät)' vs 'Who and/or what authored the Hospital Discharge Report' |
| Information | StructureDefinition.definition | Values for definition differ: 'Identifies who is responsible for the information in the composition, not necessarily who typed it in.' vs 'Identifies who is responsible for the information in the Hospital Discharge Report, not necessarily who typed it in.' |
| Warning | Composition.author | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Error | Composition.author | Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/PractitionerRole], CanonicalType[http://hl7.org/fhir/StructureDefinition/Device], CanonicalType[http://hl7.org/fhir/StructureDefinition/Organization], CanonicalType[http://hl7.org/fhir/StructureDefinition/RelatedPerson], CanonicalType[http://hl7.org/fhir/StructureDefinition/Patient], CanonicalType[http://hl7.org/fhir/StructureDefinition/Practitioner]]) vs Reference([CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core], CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core], CanonicalType[http://hl7.org/fhir/StructureDefinition/Device], CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core]]) |
| Information | StructureDefinition.short | Values for short differ: 'Dokumentenbezeichnung' vs 'Hospital Discharge Report' |
| Information | StructureDefinition.definition | Values for definition differ: 'Official human-readable label for the composition.' vs 'Official human-readable label for the composition. For this document should be 'Hospital Discharge Report' or any equivalent translation' |
| Information | StructureDefinition.comment | Values for comment differ: 'Die Dokumentenbezeichnung dient der Darstellung des Dokumentes in einer Übersicht, z.B. in einer Patientenakte, und KANN der schnellen Auffindbarkeit eines gesuchten Dokumentes dienen. Geeignete Bezeichnungen sind zum Beispiel: * "Kleines Blutbild vom 13.10.2020" * "Pathologiebefund (Abstrich) vom 13.10.2020" * "Blutgasmessung vom 13.10.2020 14:14h"' vs 'For many compositions, the title is the same as the text or a display name of Composition.type (e.g. a 'consultation' or 'progress note'). Note that CDA does not make title mandatory, but there are no known cases where it is useful for title to be omitted, so it is mandatory here. Feedback on this requirement is welcome during the trial use period.' |
| Warning | Composition.title | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'personal | professional | legal | official' vs 'The type of attestation' |
| Information | StructureDefinition.short | Values for short differ: 'When the composition was attested' vs 'When the composition was attested.' |
| Information | StructureDefinition.short | Values for short differ: 'Who attested the composition' vs 'Who attested the composition.' |
| Error | Composition.attester.party | Type Mismatch: Reference([CanonicalType[http://hl7.org/fhir/StructureDefinition/Patient], CanonicalType[http://hl7.org/fhir/StructureDefinition/RelatedPerson], CanonicalType[http://hl7.org/fhir/StructureDefinition/Practitioner], CanonicalType[http://hl7.org/fhir/StructureDefinition/PractitionerRole], CanonicalType[http://hl7.org/fhir/StructureDefinition/Organization]]) vs Reference([CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/practitioner-eu-core], CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/practitionerRole-eu-core], CanonicalType[http://hl7.eu/fhir/base/StructureDefinition/organization-eu-core]]) |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'Kapitel' vs 'Sections composing the Hospital Discharge Report' |
| Information | StructureDefinition.definition | Values for definition differ: 'The root of the sections that make up the composition.' vs 'The root of the sections that make up the Hospital Discharge Report composition.' |
| Warning | Composition.section | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | StructureDefinition.requirements | Values for requirements differ: 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](extensibility.html#modifierExtension).' vs 'Modifier extensions allow for extensions that *cannot* be safely ignored to be clearly distinguished from the vast majority of extensions which can be safely ignored. This promotes interoperability by eliminating the need for implementers to prohibit the presence of extensions. For further information, see the [definition of modifier extensions](http://hl7.org/fhir/R4/extensibility.html#modifierExtension).' |
| Information | StructureDefinition.short | Values for short differ: 'Kapitelbezeichnung' vs 'Label for section (e.g. for ToC)' |
| Warning | Composition.section.title | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Composition.section.title | Element minimum cardinalities differ: '1' vs '0' |
| Information | StructureDefinition.short | Values for short differ: 'Narrativ' vs 'Text summary of the section, for human interpretation' |
| Information | StructureDefinition.comment | Values for comment differ: 'menschenlesbare HTML-Repräsentation des Inhalts dieses Kapitels. Hinweise: Für Aggregation einer vollständigen menschenlesbaren Repräsentation MÜSSEN die Repräsentationen der einzelnen Kapitel an die Repräsentation der Metadaten (Composition.text) angehängt werden. Für die Separierung KÖNNEN einfache <div>-Tags verwendet werden. Es ist zu beachten, dass Kapitel auch Unterkapitel enthalten KÖNNEN (Composition.section.section), die bei der Aggregation entsprechend berücksichtigt werden MÜSSEN. Die Mindestanforderungen an den Inhalt der menschenlesbaren Repräsentation umfasst folgende Informationen: * `section.title` + Freitext oder * `section.title` + `Resource.text` der referenzierten Ressource oder * `section.title` + eine aggregierte Repräsentation von `Resource.text`, wenn in einer Section mehrere Ressourcen referenziert werden (z.B. eine tabellarische Auflistung mehrere Blutdruckmesswerte, Diagnosen oder Allergien).' vs 'Document profiles may define what content should be represented in the narrative to ensure clinical safety.' |
| Warning | Composition.section.text | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Information | Composition.section.text | Element minimum cardinalities differ: '1' vs '0' |
| Information | StructureDefinition.short | Values for short differ: 'Unterkapitel' vs 'Nested Section' |
| Warning | Composition.section.section | Elements differ in definition for mustSupport: 'true' vs 'false' |
| Name | Value | Comments | |
|---|---|---|---|
 abstract | false | ||
| baseDefinition | http://hl7.org/fhir/StructureDefinition/Composition | ||
| copyright | Used by permission of HL7 Europe, all rights reserved Creative Commons License |
| |
| date | 2025-06-26 | 2025-06-03T12:48:49+02:00 |
|
| description | Dieses Profil ermöglicht die krankenhaus-interne Übermittlung eines Berichtes bestehend aus beliebigen strukturierten FHIR-Ressourcen sowie einer textuellen HTML-Repräsentation (Narrative) an einen ISiK-Basis-kompatiblen Server. ### Motivation In der heterogenen Systemlandschaft im Krankenhaus sind eine Vielzahl spezialisierter Subsysteme im Einsatz. Die Ergebnisse aus diesen Subsystemen sind aktuell jedoch häufig nicht in den Primärsystemen des Krankenhauses verfügbar, denn es bestehen folgende Herausforderungen: Die Daten in Subsystemen sind sehr heterogen und können hochspezialisiert sein. Bei der Nutzung dieser Subsysteme besteht häufig ein Interesse, auf die menschenlesbare Repräsentation der strukturierten Daten einwirken zu können. Künftig ist mit Szenarien zu rechnen, bei denen Befunde aus Subsystemen in eine elektronische Patientenakte übertragen werden sollen. Aktuell werden Befunde, obwohl diese in den Subsystemen in hochstrukturierter Form vorliegen, nur als PDF an das Primärsystem übermittelt. Oft weil kein strukturiertes Format spezifiziert ist, das sowohl versendendes Subsystem als auch empfangendes Primärsystem implementiert haben. Der Umfang, in dem eine Datenübernahme in ein Primärsystem möglich ist, variiert stark zwischen den Systemen oder Installationen, z.B. abhängig davon, ob ein Modul für Vitalparameter installiert ist. Die ISiK-Spezifikation begegnet diesen Herausforderungen, indem sie die Übermittlung von Ergebnissen aus Subsystemen an die Primärsysteme in Form von strukturierten Dokumenten erfordert, die über eine menschenlesbare Repräsentation verfügen. Diese strukturierten Dokumente werden im ISiK-Kontext als Berichte bezeichnet. Dabei sind die strukturierten Inhalte der Berichte harmonisiert mit den verbreiteten Formaten für Primärsysteme. (Semi-)Strukturierte Dokumente werden in FHIR mit der `Composition`-Ressource repräsentiert, die die Dokumentenmetadaten sowie die textuelle Repräsentation des Dokumentes enthält. Die Composition referenziert auf beliebige weiter FHIR-Ressourcen, die die strukturierten Komponenten des Dokumentes darstellen. Für den Transport wird die Composition zusammen mit allen direkt oder indirekt referenzierten Ressourcen in eine `Bundle`-Ressource vom Typ `document` aggregiert. Das Document-Bundle trägt alle Eigenschaften eines Dokumentes: Abgeschlossenheit, Unveränderbarkeit, Signierbarkeit. Es obliegt dem empfangenden System, ob dieses Dokument lediglich in seiner Gesamtheit persistiert wird, oder ob darüber hinaus einzelne Bestandteile (Ressourcen) als strukturierte Daten automatisch oder auf Veranlassung eines Benutzers in die Patientenakte übernommen werden. In der aktuellen Ausbaustufe von ISiK ist lediglich die Übernahme und Anzeige der Dokument-Metadaten (z.B. Dokumenttyp, Dokumentdatum, Quelle) und der menschenlesbaren HTML-Repräsentation in die Primärsysteme erforderlich. In weiteren Ausbaustufen von ISiK soll darüber hinaus eine Übernahme der strukturierten Anteile der Dokumente möglich sein, die den ISiK-Spezifikationen entsprechen, z.B. Diagnosen und Prozeduren. ### Kompatibilität Hinweise zu Inkompatibilitäten können über die [Portalseite](https://service.gematik.de/servicedesk/customer/portal/16) gemeldet werden. | Clinical document used to represent a Hospital Discharge Report (HDR) for the scope of this guide. |
|
| experimental | false |
| |
| fhirVersion | 4.0.1 | ||
| jurisdiction | |||
 jurisdiction[0] | http://unstats.un.org/unsd/methods/m49/m49.htm#150 |
| |
| kind | resource | ||
| name | ISiKBerichtSubSysteme | CompositionEuHdr |
|
| publisher | gematik GmbH | HL7 Europe |
|
| purpose | |||
| status | active | draft |
|
| title | Composition (HDR) |
| |
| type | Composition | ||
| url | https://gematik.de/fhir/isik/StructureDefinition/ISiKBerichtSubSysteme | http://hl7.eu/fhir/hdr/StructureDefinition/composition-eu-hdr |
|
| version | 5.0.0 | 0.1.0-ballot |
|
| Name | L Flags | L Card. | L Type | L Description & Constraints | R Flags | R Card. | R Type | R Description & Constraints | Comments | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
 Composition | 0..* | Composition | A set of resources composed into a single coherent clinical statement with clinical attestation | C | 0..* | Composition | Hospital Discharge Report composition text-or-section: A Composition SHALL have either text, at least one section, or both. | ||||||||||
 id | Σ | 0..1 | string | Logical id of this artifact | Σ | 0..1 | id | Logical id of this artifact | |||||||||
| meta | Σ | 0..1 | Meta | Metadata about the resource | Σ | 0..1 | Meta | Metadata about the resource | |||||||||
| implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ?!Σ | 0..1 | uri | A set of rules under which this content was created | |||||||||
| language | 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| 0..1 | code | Language of the resource content Binding: ?? (preferred): A human language.
| |||||||||||
| text | S | 1..1 | Narrative | Narrativ | 0..1 | Narrative | Text summary of the resource, for human interpretation |
| |||||||||
 id | 0..1 | string | Unique id for inter-element referencing |
| |||||||||||||
 Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
| |||||||||||||
| status | S | 1..1 | code | generated | extensions | additional | empty Binding: ?? (required): The status of a resource narrative. Fixed Value: extensions |
| ||||||||||||
| div | SC | 1..1 | xhtml | Limited xhtml content txt-1: 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 txt-2: The narrative SHALL have some non-whitespace content |
| ||||||||||||
| contained | 0..* | Resource | Contained, inline Resources | 0..* | Resource | Contained, inline Resources | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||||||||
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ?! | 0..* | Extension | Extensions that cannot be ignored | |||||||||
| identifier | SΣ | 1..1 | Identifier | Eindeutige Dokumenten-ID | Σ | 0..1 | Identifier | HDR business identifier |
| ||||||||
| id | 0..1 | string | Unique id for inter-element referencing |
| |||||||||||||
| Slices for 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: ?? (required): Identifies the purpose for this identifier, if known . |
| ||||||||||||
| type | Σ | 0..1 | CodeableConcept | Description of identifier Binding: ?? (extensible): A coded type for an identifier that can be used to determine which identifier to use for a specific purpose. |
| ||||||||||||
| 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: ?? (required): The workflow/clinical status of the composition. Fixed Value: final | ?!Σ | 1..1 | code | HDR status Binding: ?? (required): The workflow/clinical status of the composition. |
| ||||||||
| type | SΣ | 1..1 | CodeableConcept | Dokumenttyp Binding: ?? (preferred): Type of a composition. | Σ | 1..1 | ?? | Kind of composition ("Hospital Discharge Report") Binding: ?? (preferred): Type of a composition. Required Pattern: {"coding":[{"system":"http://loinc.org","code":"34105-7","display":"Hospital Discharge summary"}]} |
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| id | 0..1 | string | Unique id for inter-element referencing |
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| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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| Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
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| text | SΣ | 0..1 | string | Dokumenttyp (Freitext) |
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| category | SΣ | 0..* | CodeableConcept | Dokument-Kategorie Binding: ?? (example): High-level kind of a clinical document at a macro level. | Σ | 0..* | CodeableConcept | Categorization of Composition Binding: ?? (example): High-level kind of a clinical document at a macro level. |
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| id | 0..1 | string | Unique id for inter-element referencing |
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| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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| Slices for coding | SΣ | 0..* | Coding | Code defined by a terminology system Slice: Unordered, Open by pattern:$this |
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| text | Σ | 0..1 | string | Plain text representation of the concept |
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| subject | SΣ | 1..1 | Reference(Resource) | Patientenbezug | Σ | 1..1 | Reference(Patient (EU core)) | Who and/or what the composition is about |
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| id | 0..1 | string | Unique id for inter-element referencing |
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| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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| reference | SΣC | 1..1 | string | Patienten-Link |
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| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). |
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| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
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| display | Σ | 0..1 | string | Text alternative for the resource |
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| encounter | SΣ | 0..1 | Reference(Encounter) | Aufenthaltsbezug | Σ | 0..1 | Reference(Encounter (HDR)) | Context of the Composition |
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| id | 0..1 | string | Unique id for inter-element referencing |
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| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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| reference | SΣC | 1..1 | string | Encounter-Link |
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| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). |
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| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
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| display | Σ | 0..1 | string | Text alternative for the resource |
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| date | SΣ | 1..1 | dateTime | Dokumentendatum | Σ | 1..1 | dateTime | HDR date |
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| author | SΣ | 1..* | Reference(PractitionerRole | Device | Organization | RelatedPerson | Patient | Practitioner) | Verfasser/Ersteller des Dokumentes (Person oder Subsystem/Gerät) | Σ | 1..* | Reference(Practitioner (EU core) | PractitionerRole (EU core) | Device | Organization (EU core)) | Who and/or what authored the Hospital Discharge Report |
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| id | 0..1 | string | Unique id for inter-element referencing |
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| Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url |
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| reference | ΣC | 0..1 | string | Literal reference, Relative, internal or absolute URL |
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| type | Σ | 0..1 | uri | Type the reference refers to (e.g. "Patient") Binding: ?? (extensible): Aa resource (or, for logical models, the URI of the logical model). |
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| identifier | Σ | 0..1 | Identifier | Logical reference, when literal reference is not known |
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| display | SΣ | 1..1 | string | Bezeichnung des Verfassers (Freitext) |
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| title | SΣ | 1..1 | string | Dokumentenbezeichnung | Σ | 1..1 | string | Hospital Discharge Report |
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| confidentiality | Σ | 0..1 | code | As defined by affinity domain Binding: ?? (required): Codes specifying the level of confidentiality of the composition. | Σ | 0..1 | code | As defined by affinity domain Binding: ?? (required): Codes specifying the level of confidentiality of the composition. | |||||||||
| attester | 0..* | BackboneElement | Attests to accuracy of composition | 0..* | BackboneElement | Attests to accuracy of composition | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| mode | 1..1 | code | personal | professional | legal | official Binding: ?? (required): The way in which a person authenticated a composition. | 1..1 | code | The type of attestation Binding: ?? (required): The way in which a person authenticated a composition. | |||||||||||
| time | 0..1 | dateTime | When the composition was attested | 0..1 | dateTime | When the composition was attested. | |||||||||||
| party | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole | Organization) | Who attested the composition | 0..1 | Reference(Practitioner (EU core) | PractitionerRole (EU core) | Organization (EU core)) | Who attested the composition. |
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| custodian | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | Σ | 0..1 | Reference(Organization) | Organization which maintains the composition | |||||||||
| relatesTo | 0..* | BackboneElement | Relationships to other compositions/documents | 0..* | BackboneElement | Relationships to other compositions/documents | |||||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| code | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | 1..1 | code | replaces | transforms | signs | appends Binding: ?? (required): The type of relationship between documents. | |||||||||||
| target[x] | 1..1 | Identifier, Reference(Composition) | Target of the relationship | 1..1 | Identifier, Reference(Composition) | Target of the relationship | |||||||||||
| event | Σ | 0..* | BackboneElement | The clinical service(s) being documented | Σ | 0..* | BackboneElement | The clinical service(s) being documented | |||||||||
| id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!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: ?? (example): This list of codes represents the main clinical acts being documented. | Σ | 0..* | CodeableConcept | Code(s) that apply to the event being documented Binding: ?? (example): This list of codes represents the main clinical acts being documented. | |||||||||
| period | Σ | 0..1 | Period | The period covered by the documentation | Σ | 0..1 | Period | The period covered by the documentation | |||||||||
| detail | Σ | 0..* | Reference(Resource) | The event(s) being documented | Σ | 0..* | Reference(Resource) | The event(s) being documented | |||||||||
| section | SC | 1..* | BackboneElement | Kapitel cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty | C | 1..* | BackboneElement | Sections composing the Hospital Discharge Report Slice: Unordered, Open by value:code cmp-1: A section must contain at least one of text, entries, or sub-sections cmp-2: A section can only have an emptyReason if it is empty |
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 id | 0..1 | string | Unique id for inter-element referencing | 0..1 | string | Unique id for inter-element referencing | |||||||||||
| extension | 0..* | Extension | Additional content defined by implementations | 0..* | Extension | Additional content defined by implementations | |||||||||||
| modifierExtension | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | ?!Σ | 0..* | Extension | Extensions that cannot be ignored even if unrecognized | |||||||||
| title | S | 1..1 | string | Kapitelbezeichnung | 0..1 | string | Label for section (e.g. for ToC) |
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| code | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | 0..1 | CodeableConcept | Classification of section (recommended) Binding: ?? (example): Classification of a section of a composition/document. | |||||||||||
| author | 0..* | Reference(Practitioner | PractitionerRole | Device | Patient | RelatedPerson | Organization) | Who and/or what authored the section | 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 | 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 | C | 0..1 | Narrative | Text summary of the section, for human interpretation |
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| mode | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | 0..1 | code | working | snapshot | changes Binding: ?? (required): The processing mode that applies to this section. | |||||||||||
| orderedBy | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | 0..1 | CodeableConcept | Order of section entries Binding: ?? (preferred): What order applies to the items in the entry. | |||||||||||
| entry | C | 0..* | Reference(Resource) | A reference to data that supports this section | C | 0..* | Reference(Resource) | A reference to data that supports this section | |||||||||
| emptyReason | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | C | 0..1 | CodeableConcept | Why the section is empty Binding: ?? (preferred): If a section is empty, why it is empty. | |||||||||
 section | SC | 0..* | See section (Composition) | Unterkapitel | C | 0..* | See section (Composition) | Nested Section |
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| Documentation for this format | |||||||||||||||||