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Änderungen
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{| class="wikitable" width="100%"
|-
! style="text-align:left" width="20%" | Feld||style="text-align:left" width="40%" | Element||style="text-align:left" width="20%" | Opt||style="text-align:left" width="20%" | Kapitel
|-
! style="text-align:left" colspan="4" | ''Daten zum Dokument''
|- style="background:#FFFFFF"
|Realm Code||ClinicalDocument/realmCode||''M''||Kapitel
|- style="background:#FFFFFF"
|Dokumentenformat||ClinicalDocument/typeId||''M''||
|- style="background:#FFFFFF"
|Dokumenten-ID||ClinicalDocument/id||''M''||
|- style="background:#FFFFFF"
|Vertraulichkeitscode||ClinicalDocument/confidentialityCode||''M''||
|- style="background:#FFFFFF"
|Sprachcode||ClinicalDocument/languageCode||''M''||
|- style="background:#FFFFFF"
|Template||ClinicalDocument/templateId||''M''||
|- style="background:#FFFFFF"
|Dokumenttitel||ClinicalDocument/title||''M''||
|- style="background:#FFFFFF"
|Dokumentenklasse||ClinicalDocument/code||''M''||
|- style="background:#FFFFFF"
|Dokumentdatum||ClinicalDocument/effectiveTime||''M''||
|- style="background:#FFFFFF"
|Versionierung des Dokuments||ClinicalDocument/setId<br>ClinicalDocument/versionNumber<br>||''M''||
|-
! style="text-align:left" colspan="4" | ''Teilnehmende Parteien''
|- style="background:#FFFFFF"
|Patient||ClinicalDocument/recordTarget||''M''||Kapitel
|- style="background:#FFFFFF"
|Verwalter des originalen Dokuments||ClinicalDocument/custodian||''M''||
|- style="background:#FFFFFF"
|Rechtlicher Unterzeichner||ClinicalDocument/legalAuthenticator||''M''<br/>''[1..1]''||
|- style="background:#FFFFFF"
|Verfasser des Dokuments||ClinicalDocument/author||''M''<br/>''[1..*]''||
|- style="background:#FFFFFF"
|Vorgesehener Empfänger||ClinicalDocument/informationRecipient||''O''<br/>''[0..*]''||
|- style="background:#FFFFFF"
|Validatoren||ClinicalDocument/authenticator||''O''<br/>''[0..*]''||
|-
! style="text-align:left" colspan="4" | ''Referenz zum Auftrag''
|- style="background:#FFFFFF"
|Auftraggeber (IHE „Ordering Provider“)||ClinicalDocument/participant@typeCode=“REF“||''R''<br/>''[1..1]''||Kapitel
|- style="background:#FFFFFF"
|Auftragsidentifikation||ClinicalDocument/inFulfillmentOf/order||''M''<br/>''[1..1]''||
|-
! style="text-align:left" colspan="4" | ''Dokumentation der Gesundheitsdienstleistung''
|- style="background:#FFFFFF"
|Service Events||ClinicalDocument/documentationOf/serviceEvent||''M''<br/>''[1..*]''||Kapitel
|- style="background:#FFFFFF"
|Durchführende Labors||ClinicalDocument/documentationOf/serviceEvent/performer||''O''<br/>''[0..*]''||
|-
! style="text-align:left" colspan="4" | ''Informationen zum Patientenkontakt''
|- style="background:#FFFFFF"
|Encounter||ClinicalDocument/componentOf/encompassingEncounter||''O''<br/>''[0..1]''||Kapitel
|}
|-
! style="text-align:left" width="20%" | Feld||style="text-align:left" width="40%" | Element||style="text-align:left" width="20%" | Opt||style="text-align:left" width="20%" | Kapitel
|-
! style="text-align:left" colspan="4" | ''Daten zum Dokument''
|- style="background:#FFFFFF"
|Realm Code||ClinicalDocument/realmCode||''M''||Kapitel
|- style="background:#FFFFFF"
|Dokumentenformat||ClinicalDocument/typeId||''M''||
|- style="background:#FFFFFF"
|Dokumenten-ID||ClinicalDocument/id||''M''||
|- style="background:#FFFFFF"
|Vertraulichkeitscode||ClinicalDocument/confidentialityCode||''M''||
|- style="background:#FFFFFF"
|Sprachcode||ClinicalDocument/languageCode||''M''||
|- style="background:#FFFFFF"
|Template||ClinicalDocument/templateId||''M''||
|- style="background:#FFFFFF"
|Dokumenttitel||ClinicalDocument/title||''M''||
|- style="background:#FFFFFF"
|Dokumentenklasse||ClinicalDocument/code||''M''||
|- style="background:#FFFFFF"
|Dokumentdatum||ClinicalDocument/effectiveTime||''M''||
|- style="background:#FFFFFF"
|Versionierung des Dokuments||ClinicalDocument/setId<br>ClinicalDocument/versionNumber<br>||''M''||
|-
! style="text-align:left" colspan="4" | ''Teilnehmende Parteien''
|- style="background:#FFFFFF"
|Patient||ClinicalDocument/recordTarget||''M''||Kapitel
|- style="background:#FFFFFF"
|Verwalter des originalen Dokuments||ClinicalDocument/custodian||''M''||
|- style="background:#FFFFFF"
|Rechtlicher Unterzeichner||ClinicalDocument/legalAuthenticator||''M''<br/>''[1..1]''||
|- style="background:#FFFFFF"
|Verfasser des Dokuments||ClinicalDocument/author||''M''<br/>''[1..*]''||
|- style="background:#FFFFFF"
|Vorgesehener Empfänger||ClinicalDocument/informationRecipient||''O''<br/>''[0..*]''||
|- style="background:#FFFFFF"
|Validatoren||ClinicalDocument/authenticator||''O''<br/>''[0..*]''||
|-
! style="text-align:left" colspan="4" | ''Referenz zum Auftrag''
|- style="background:#FFFFFF"
|Auftraggeber (IHE „Ordering Provider“)||ClinicalDocument/participant@typeCode=“REF“||''R''<br/>''[1..1]''||Kapitel
|- style="background:#FFFFFF"
|Auftragsidentifikation||ClinicalDocument/inFulfillmentOf/order||''M''<br/>''[1..1]''||
|-
! style="text-align:left" colspan="4" | ''Dokumentation der Gesundheitsdienstleistung''
|- style="background:#FFFFFF"
|Service Events||ClinicalDocument/documentationOf/serviceEvent||''M''<br/>''[1..*]''||Kapitel
|- style="background:#FFFFFF"
|Durchführende Labors||ClinicalDocument/documentationOf/serviceEvent/performer||''O''<br/>''[0..*]''||
|-
! style="text-align:left" colspan="4" | ''Informationen zum Patientenkontakt''
|- style="background:#FFFFFF"
|Encounter||ClinicalDocument/componentOf/encompassingEncounter||''O''<br/>''[0..1]''||Kapitel
|}
