Implementation Guide for fælleskommunal informationsmodel
1.2.0 - release
This page is part of the KLCore (v1.2.0: Release) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions
Official URL: http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialEvaluation | Version: 1.2.0 | |||
Active as of 2023-06-07 | Computable Name: KLCommonCareSocialEvaluation |
Professional evaluation on citizen status based on gathered information, conditions, observations and citizen preferences used in Danish municipalities
CommonCareSocialEvaluation is used for documenting the result of an evaluation, typically being the last part of or following an information collection process. The different kinds of evaluations currently supported are defined by FSIII and FFB, and they are “FSIII helhedsvurdering”, “FFB vurdering af borgers situation”, “FFB støttebehovsvurdering”, “VUM Borgerens perspektiv på indsatsen”, “VUM Borgerens ressourcer i forhold til indsatsen”.
The Observation.code is mandatory, and fixed to a ValueSet specified by Local Govenment Denmark (KL), which may be suplemented with a SNOMED CT code.
This resource has a text-based results in Observation.valueCodeableConcept.text, but can have a coded result as well. The coded result is only defined for structured needs assessment (FFB støttebehovsvurdering), and is represented in Observation.codeableConcept.coding. This means that Observation.codeableConcept.coding is only allowed if the Observation.code is effe55c7-572c-4a99-8fb4-2a9dda2f6572”FFB støttebehovsvurdering”, and possibly the SNOMED CT code 225344000 “Assessment of degree of assistance required (procedure)”.
The Evaluation may reference a ServiceRequest, if the evaluation is percieved as an answer to that request.
Nedenstående tabel oversætter mellem de attributter der er defineret i den fælleskommunale informationsmodel (FKI), definerer kort den enkelte attribut på dansk og specificerer, hvilke af FHIR-profilens atributter der skal bruges til specifikation af indholdet.
FKI-attribut | Definition | FHIR |
---|---|---|
vurderingskode | Klasse der udtrykker typen af vurdering. | Observation.code |
vurderingsresultat | Tekst der udgør vurderingsresultatet. | Observation.valueCodeableConcept.text |
struktureretVurdering | En struktureret støttebehovsvurdering. | Observation.valueCodeableConcept.coding |
vurderingssubjekt | Den borger der vurderes. | Observation.subject |
vurderingskontakt | Den kontakt, hvor vurderingen gennemføres. | Observation.encounter |
vurderingsansvarlig | Den fagperson der er ansvarlig for vurderingen. | Observation.performer |
vurderingBaseretPå | Den henvendelse/henvisning som vurderingen er opsummering/svar på. | Observation.basedOn |
vurderingstid | Det tidspunkt hvor vurderingen er foretaget. | Observation.effectiveDateTime |
vurderingsstatus | Klasse der udtrykker, hvor i sin proces, vurderingen er. | Observation.status |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
basedOn | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå | |
status | 1..1 | code | [DK] vurderingsstatus | |
code | 1..1 | CodeableConcept | [DK] vurderingskode | |
Slices for coding | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
coding:klEvaluationCode | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes | |
coding:sctEvaluationCode | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | |
subject | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt | |
encounter | 0..1 | Reference(Encounter) | [DK] vurderingskontakt | |
effective[x] | 1..1 | dateTime | [DK] vurderingstid | |
performer | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig | |
value[x] | 0..1 | CodeableConcept | Actual result | |
coding | 0..* | Coding | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) | |
text | 0..1 | string | [DK] vurderingsresultat | |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes |
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT |
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå |
status | ?!Σ | 1..1 | code | [DK] vurderingsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | Σ | 1..1 | CodeableConcept | [DK] vurderingskode Binding: LOINCCodes (example): Codes identifying names of simple observations. |
Slices for coding | Σ | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
coding:klEvaluationCode | Σ | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes |
coding:sctEvaluationCode | Σ | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
subject | Σ | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt |
encounter | Σ | 0..1 | Reference(Encounter) | [DK] vurderingskontakt |
effective[x] | Σ | 1..1 | dateTime | [DK] vurderingstid |
performer | Σ | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig |
value[x] | ΣC | 0..1 | CodeableConcept | Actual result |
coding | Σ | 0..* | Coding | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) |
text | Σ | 0..1 | string | [DK] vurderingsresultat |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.code | example | LOINCCodes (a valid code from LOINC) |
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes |
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT |
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | [DK] vurderingsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
code | Σ | 1..1 | CodeableConcept | [DK] vurderingskode Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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 | Σ | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:klEvaluationCode | Σ | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) | ||||
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 Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes | ||||
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 | ||||
coding:sctEvaluationCode | Σ | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) | ||||
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 Required Pattern: 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 | Σ | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt | ||||
focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | [DK] vurderingskontakt | ||||
effective[x] | Σ | 1..1 | dateTime | [DK] vurderingstid | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig | ||||
value[x] | ΣC | 0..1 | CodeableConcept | Actual result | ||||
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 | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) | ||||
text | Σ | 0..1 | string | [DK] vurderingsresultat | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation | ||||
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 | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
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 | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes | ||||
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT | ||||
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretationCodes | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from Observation
Summary
Mandatory: 4 elements (1 nested mandatory element)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
basedOn | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå | |
status | 1..1 | code | [DK] vurderingsstatus | |
code | 1..1 | CodeableConcept | [DK] vurderingskode | |
Slices for coding | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | |
coding:klEvaluationCode | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes | |
coding:sctEvaluationCode | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | |
subject | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt | |
encounter | 0..1 | Reference(Encounter) | [DK] vurderingskontakt | |
effective[x] | 1..1 | dateTime | [DK] vurderingstid | |
performer | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig | |
value[x] | 0..1 | CodeableConcept | Actual result | |
coding | 0..* | Coding | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) | |
text | 0..1 | string | [DK] vurderingsresultat | |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes |
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT |
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions |
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå |
status | ?!Σ | 1..1 | code | [DK] vurderingsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | Σ | 1..1 | CodeableConcept | [DK] vurderingskode Binding: LOINCCodes (example): Codes identifying names of simple observations. |
Slices for coding | Σ | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system |
coding:klEvaluationCode | Σ | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes |
coding:sctEvaluationCode | Σ | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
subject | Σ | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt |
encounter | Σ | 0..1 | Reference(Encounter) | [DK] vurderingskontakt |
effective[x] | Σ | 1..1 | dateTime | [DK] vurderingstid |
performer | Σ | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig |
value[x] | ΣC | 0..1 | CodeableConcept | Actual result |
coding | Σ | 0..* | Coding | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) |
text | Σ | 0..1 | string | [DK] vurderingsresultat |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.code | example | LOINCCodes (a valid code from LOINC) |
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes |
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT |
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Observation | C | 0..* | Observation | Measurements and simple assertions | ||||
id | Σ | 0..1 | id | Logical id of this artifact | ||||
meta | Σ | 0..1 | Meta | Metadata about the resource | ||||
implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created | ||||
language | 0..1 | code | Language of the resource content Binding: CommonLanguages (preferred): A human language.
| |||||
text | 0..1 | Narrative | Text summary of the resource, for human interpretation | |||||
contained | 0..* | Resource | Contained, inline Resources | |||||
extension | 0..* | Extension | Additional content defined by implementations | |||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | Business Identifier for observation | ||||
basedOn | Σ | 0..* | Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest) | [DK] vurderingBaseretPå | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | [DK] vurderingsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. | ||||
category | 0..* | CodeableConcept | Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories. | |||||
code | Σ | 1..1 | CodeableConcept | [DK] vurderingskode Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
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 | Σ | 1..2 | Coding | Code defined by a terminology system Slice: Unordered, Open by value:system | ||||
coding:klEvaluationCode | Σ | 1..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoder (required) | ||||
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 Required Pattern: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes | ||||
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 | ||||
coding:sctEvaluationCode | Σ | 0..1 | Coding | Code defined by a terminology system Binding: KLVurderingTypekoderSCT (required) | ||||
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 Required Pattern: 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 | Σ | 0..1 | Reference(Citizen) | [DK] vurderingssubjekt | ||||
focus | ΣTU | 0..* | Reference(Resource) | What the observation is about, when it is not about the subject of record | ||||
encounter | Σ | 0..1 | Reference(Encounter) | [DK] vurderingskontakt | ||||
effective[x] | Σ | 1..1 | dateTime | [DK] vurderingstid | ||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practioner) | [DK] vurderingsansvarlig | ||||
value[x] | ΣC | 0..1 | CodeableConcept | Actual result | ||||
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 | [DK] struktureretVurdering Binding: KLStøttebehovsvurderingskoderFFB (required) | ||||
text | Σ | 0..1 | string | [DK] vurderingsresultat | ||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
note | 0..* | Annotation | Comments about the observation | |||||
bodySite | 0..1 | CodeableConcept | Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | |||||
method | 0..1 | CodeableConcept | How it was done Binding: ObservationMethods (example): Methods for simple observations. | |||||
specimen | 0..1 | Reference(Specimen) | Specimen used for this observation | |||||
device | 0..1 | Reference(Device | DeviceMetric) | (Measurement) Device | |||||
referenceRange | C | 0..* | BackboneElement | Provides guide for interpretation | ||||
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 | ||||
low | C | 0..1 | SimpleQuantity | Low Range, if relevant | ||||
high | C | 0..1 | SimpleQuantity | High Range, if relevant | ||||
type | 0..1 | CodeableConcept | Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range. | |||||
appliesTo | 0..* | CodeableConcept | Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to. | |||||
age | 0..1 | Range | Applicable age range, if relevant | |||||
text | 0..1 | string | Text based reference range in an observation | |||||
hasMember | Σ | 0..* | Reference(Observation | QuestionnaireResponse | MolecularSequence) | Related resource that belongs to the Observation group | ||||
derivedFrom | Σ | 0..* | Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence) | Related measurements the observation is made from | ||||
component | Σ | 0..* | BackboneElement | Component results | ||||
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 | 1..1 | CodeableConcept | Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. | ||||
value[x] | Σ | 0..1 | Actual component result | |||||
valueQuantity | Quantity | |||||||
valueCodeableConcept | CodeableConcept | |||||||
valueString | string | |||||||
valueBoolean | boolean | |||||||
valueInteger | integer | |||||||
valueRange | Range | |||||||
valueRatio | Ratio | |||||||
valueSampledData | SampledData | |||||||
valueTime | time | |||||||
valueDateTime | dateTime | |||||||
valuePeriod | Period | |||||||
dataAbsentReason | C | 0..1 | CodeableConcept | Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing. | ||||
interpretation | 0..* | CodeableConcept | High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations. | |||||
referenceRange | 0..* | See referenceRange (Observation) | Provides guide for interpretation of component result | |||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Observation.language | preferred | CommonLanguages
| ||||
Observation.status | required | ObservationStatus | ||||
Observation.category | preferred | ObservationCategoryCodes | ||||
Observation.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.code.coding:klEvaluationCode | required | KLEvaluationTypeCodes | ||||
Observation.code.coding:sctEvaluationCode | required | KLEvaluationTypeCodesSCT | ||||
Observation.value[x].coding | required | KLNeedsAssessmentCodesFFB | ||||
Observation.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.interpretation | extensible | ObservationInterpretationCodes | ||||
Observation.bodySite | example | SNOMEDCTBodyStructures | ||||
Observation.method | example | ObservationMethods | ||||
Observation.referenceRange.type | preferred | ObservationReferenceRangeMeaningCodes | ||||
Observation.referenceRange.appliesTo | example | ObservationReferenceRangeAppliesToCodes | ||||
Observation.component.code | example | LOINCCodes (a valid code from LOINC) | ||||
Observation.component.dataAbsentReason | extensible | DataAbsentReason | ||||
Observation.component.interpretation | extensible | ObservationInterpretationCodes |
This structure is derived from Observation
Summary
Mandatory: 4 elements (1 nested mandatory element)
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron