Die offiziell beschlossene Version des Informationsmodells befinden sich auf ART DECOR. Zur Vereinheitlichung der Repräsentation wurde das Informationsmodell zusätzlich als FHIR Logical Model abgebildet:
| MII_LM_Dokument (mii-lm-dokument) | Element | Element idmii-lm-dokumentShort description MII LM Dokument DefinitionMII Logical Model KDS-Modul Dokument The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idmii-lm-dokument.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| Dokument | 1..1 | BackboneElement | Element idmii-lm-dokument.DokumentShort description Dokument DefinitionKlinisches Dokument inkl. Metadaten, Inhalt, Erzeugungskontext und Beziehungen The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| Masteridentifikator | 0..1 | Identifier | Element idmii-lm-dokument.Dokument.MasteridentifikatorShort description Versionsspezifische Kennung DefinitionVersionsspezifische eindeutige Kennung, die dem Dokument durch die Dokumentenquelle zugewiesen wurde The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Businessidentifikator | 0..1 | Identifier | Element idmii-lm-dokument.Dokument.BusinessidentifikatorShort description Versionsunabhängige Kennung DefinitionAndere versionsunabhängige Kennung, die dem Dokument (z.B. durch weitere dokumentenverarbeitende Systeme) zugewiesen wurde The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Dokumentenreferenzstatus | 1..1 | code | Element idmii-lm-dokument.Dokument.DokumentenreferenzstatusShort description Status der Dokumentenreferenz DefinitionStatus dieser Dokumentenreferenz (aktuell, überholt oder irrtümlich eingegeben)
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| Dokumentenstatus | 0..1 | code | Element idmii-lm-dokument.Dokument.DokumentenstatusShort description Status des Dokuments DefinitionStatus des zugrunde liegenden Dokuments (vorläufig, final, geändert oder irrtümlich eingegeben)
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| Dokumententyp | 0..1 | code | Element idmii-lm-dokument.Dokument.DokumententypShort description Art des Dokuments DefinitionArt des Dokuments auf das verwiesen wird (z.B. Anamnese und Untersuchung, Entlassungsbericht, Verlaufsbericht)
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| Dokumentenkategorie | 0..* | code | Element idmii-lm-dokument.Dokument.DokumentenkategorieShort description Kategorien des Dokuments DefinitionÜbergeordnete Kategorie des Dokuments auf das verwiesen wird (z.B. Arztberichte oder Arztdokumentation)
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| Patient | 0..1 | Identifier | Element idmii-lm-dokument.Dokument.PatientShort description Verweis auf Patient DefinitionPatient auf den sich das verwiesene Dokument bezieht The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Beschreibung | 0..1 | string | Element idmii-lm-dokument.Dokument.BeschreibungShort description Beschreibung des Dokuments DefinitionMenschenlesbare Beschreibung zum verwiesenen Dokuments Note that FHIR strings SHALL NOT exceed 1MB in size
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| Sicherheitsstufe | 0..* | code | Element idmii-lm-dokument.Dokument.SicherheitsstufeShort description Vertraulichkeit des Dokuments DefinitionGrad der Vertraulichkeit/Sicherheit des verwiesenen Dokuments (z. B. uneingeschränkt, gering, mittel, normal oder eingeschränkt)
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| Dokumentenbeziehung | 0..* | BackboneElement | Element idmii-lm-dokument.Dokument.DokumentenbeziehungShort description Beziehung des Dokuments DefinitionBeziehungen des verwiesenen Dokuments zu anderen Dokumenten The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Dokumentenbeziehung.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Dokumentenbeziehung.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Dokumentenbeziehung.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| Beziehungstyp | 1..1 | code | Element idmii-lm-dokument.Dokument.Dokumentenbeziehung.BeziehungstypShort description Art der Beziehung DefinitionBeziehung zu anderen Dokumenten
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| Beziehungsreferenz | 1..1 | Identifier | Element idmii-lm-dokument.Dokument.Dokumentenbeziehung.BeziehungsreferenzShort description Verweis auf Dokument DefinitionZiel der Dokumentenbeziehung The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Anhang | 1..* | BackboneElement | Element idmii-lm-dokument.Dokument.AnhangShort description Inhalt des Dokuments DefinitionDokument (Base64-kodierte Daten) oder Verweis (URL) mit relevanten Metadaten zum Anhang The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Anhang.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Anhang.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Anhang.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| Sprache | 0..1 | code | Element idmii-lm-dokument.Dokument.Anhang.SpracheShort description Verfassungssprache des Inhalts DefinitionVerwendete Sprache in dem Dokument
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| Erstellungsdatum | 0..1 | dateTime | Element idmii-lm-dokument.Dokument.Anhang.ErstellungsdatumShort description Erstellungsdatum des Inhalts DefinitionDatum der Erstellung des Dokumentes
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| Daten | 0..1 | base64Binary | Element idmii-lm-dokument.Dokument.Anhang.DatenShort description Binärdaten zum Inhalt DefinitionDokument als Binärdaten A stream of bytes, base64 encoded
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| DokumentenUrl | 0..1 | string | Element idmii-lm-dokument.Dokument.Anhang.DokumentenUrlShort description URL zum Inhalt DefinitionVerweis auf den (lokalen) Ablageort des Dokuments Note that FHIR strings SHALL NOT exceed 1MB in size
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| Dokumentenformat | 0..1 | code | Element idmii-lm-dokument.Dokument.Anhang.DokumentenformatShort description MIME-Typ zum Inhalt DefinitionMIME-Typ des Dokumenteninhalts
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| Kontext | 0..1 | BackboneElement | Element idmii-lm-dokument.Dokument.KontextShort description Erzeugungskontext des Dokuments DefinitionKlinischer Kontext, in welchem das Dokument erzeugt wurde The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| id | 0..1 | string | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Kontext.idShort description Unique id for inter-element referencing DefinitionUnique id for the element within a resource (for internal references). This may be any string value that does not contain spaces.
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| extension | C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Kontext.extensionShort description Additional content defined by implementations Alternate namesextensions, user content DefinitionMay be used to represent additional information that is not part of the basic definition of the element. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone. Unordered, Open, by url(Value) Extensions are always sliced by (at least) url Constraints
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| modifierExtension | Σ ?! C | 0..* | Extension | There are no (further) constraints on this element Element idmii-lm-dokument.Dokument.Kontext.modifierExtensionShort description Extensions that cannot be ignored even if unrecognized Alternate namesextensions, user content, modifiers DefinitionMay be used to represent additional information that is not part of the basic definition of the element and that modifies the understanding of the element in which it is contained and/or the understanding of the containing element's descendants. Usually modifier elements provide negation or qualification. To make the use of extensions safe and manageable, there is a strict set of governance applied to the definition and use of extensions. Though any implementer can define an extension, there is a set of requirements that SHALL be met as part of the definition of the extension. Applications processing a resource are required to check for modifier extensions. Modifier extensions SHALL NOT change the meaning of any elements on Resource or DomainResource (including cannot change the meaning of modifierExtension itself). 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. There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.
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| Gesundheitseinrichtungskontakt | 0..* | Identifier | Element idmii-lm-dokument.Dokument.Kontext.GesundheitseinrichtungskontaktShort description Verweis auf Einrichtungskontakt DefinitionKontakt zur Gesundheitseinrichtung oder die Art der Versorgung, die mit dem Dokumenteninhalt assoziiert ist The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Vorgang | 0..* | code | Element idmii-lm-dokument.Dokument.Kontext.VorgangShort description Dokumentierter Vorgang DefinitionHandlungen oder Prozeduren, die im Kontext dokumentiert wurden
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| Fachgebiet | 0..1 | code | Element idmii-lm-dokument.Dokument.Kontext.FachgebietShort description Klinisches Fachgebiet zum Vorgang DefinitionKlinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde
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| Dokumentationszeitraum | C | 0..1 | Period | Element idmii-lm-dokument.Dokument.Kontext.DokumentationszeitraumShort description Durchführungszeitraum zum Vorgang DefinitionZeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde A Period specifies a range of time; the context of use will specify whether the entire range applies (e.g. "the patient was an inpatient of the hospital for this time range") or one value from the range applies (e.g. "give to the patient between these two times"). Period is not used for a duration (a measure of elapsed time). See Duration. The cardinality or value of this element may be affected by these constraints: ele-1 Constraints
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| Einrichtungsart | 0..1 | code | Element idmii-lm-dokument.Dokument.Kontext.EinrichtungsartShort description Art der Einrichtung zum Vorgang DefinitionArt der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte
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Es ist zu beachten, dass das Logical Model rein auf die Abbildung der Datenelemente und deren Beschreibung abzielt. Verwendete Datentypen und Kardinalitäten sind nicht als verpflichtend anzusehen. Dies wird abschließend durch die FHIR-Profile festgelegt. Für jedes Element innerhalb des Logical Models existiert ein 1:1 Mapping auf ein Element einer konkreten FHIR Ressource.
| Logischer Datensatz | Beschreibung |
|---|---|
| mii-lm-dokument | MII Logical Model KDS-Modul Dokument |
| Dokument | Klinisches Dokument inkl. Metadaten, Inhalt, Erzeugungskontext und Beziehungen |
| Dokument. Masteridentifikator | Versionsspezifische eindeutige Kennung, die dem Dokument durch die Dokumentenquelle zugewiesen wurde |
| Dokument. Businessidentifikator | Andere versionsunabhängige Kennung, die dem Dokument (z.B. durch weitere dokumentenverarbeitende Systeme) zugewiesen wurde |
| Dokument. Dokumentenreferenzstatus | Status dieser Dokumentenreferenz (aktuell, überholt oder irrtümlich eingegeben) |
| Dokument. Dokumentenstatus | Status des zugrunde liegenden Dokuments (vorläufig, final, geändert oder irrtümlich eingegeben) |
| Dokument. Dokumententyp | Art des Dokuments auf das verwiesen wird (z.B. Anamnese und Untersuchung, Entlassungsbericht, Verlaufsbericht) |
| Dokument. Dokumentenkategorie | Übergeordnete Kategorie des Dokuments auf das verwiesen wird (z.B. Arztberichte oder Arztdokumentation) |
| Dokument. Patient | Patient auf den sich das verwiesene Dokument bezieht |
| Dokument. Beschreibung | Menschenlesbare Beschreibung zum verwiesenen Dokuments |
| Dokument. Sicherheitsstufe | Grad der Vertraulichkeit/Sicherheit des verwiesenen Dokuments (z. B. uneingeschränkt, gering, mittel, normal oder eingeschränkt) |
| Dokument. Dokumentenbeziehung | Beziehungen des verwiesenen Dokuments zu anderen Dokumenten |
| Dokument. Dokumentenbeziehung. Beziehungstyp | Beziehung zu anderen Dokumenten |
| Dokument. Dokumentenbeziehung. Beziehungsreferenz | Ziel der Dokumentenbeziehung |
| Dokument. Anhang | Dokument (Base64-kodierte Daten) oder Verweis (URL) mit relevanten Metadaten zum Anhang |
| Dokument. Anhang. Sprache | Verwendete Sprache in dem Dokument |
| Dokument. Anhang. Erstellungsdatum | Datum der Erstellung des Dokumentes |
| Dokument. Anhang. Daten | Dokument als Binärdaten |
| Dokument. Anhang. DokumentenUrl | Verweis auf den (lokalen) Ablageort des Dokuments |
| Dokument. Anhang. Dokumentenformat | MIME-Typ des Dokumenteninhalts |
| Dokument. Kontext | Klinischer Kontext, in welchem das Dokument erzeugt wurde |
| Dokument. Kontext. Gesundheitseinrichtungskontakt | Kontakt zur Gesundheitseinrichtung oder die Art der Versorgung, die mit dem Dokumenteninhalt assoziiert ist |
| Dokument. Kontext. Vorgang | Handlungen oder Prozeduren, die im Kontext dokumentiert wurden |
| Dokument. Kontext. Fachgebiet | Klinisches Fachgebiet, in dem Dokumenteninhalt erstellt wurde |
| Dokument. Kontext. Dokumentationszeitraum | Zeitraum, in dem die in dem Dokument beschriebene Handlung oder Prozedur durchgeführt wurde |
| Dokument. Kontext. Einrichtungsart | Art der Einrichtung, in der die Handlung oder Prozedur am Patienten erfolgte |
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