Scope and usage

KLCommonCareSocialCarePlan is used to document a collection of PlannedInterventions, which have a common goal or focus.

CarePlan.category specifies the different types of CarePlans and has the following valid values: Rehabilitation following the health act §140, health promotion and prevention following the health act §119, and social intervention (social indsats) as described by FFB and VUM. The latter is well-described. §140 and §119 as healthcare processes are not thorughly described by FSIII yet, but there is a recognized need, to see them as processes rather than stand-alone interventions. Consequently, attributes are designes as specified by FFB.

The CarePlan.goal have two slices because it is used to describe both the mandatory purpose of the CarePlan (indsatsformål) and any number of connected intevention goals (FFB indsatsmål). An overall description of the intended intervention activities should be provided in CarePlan.description, which have a MUST SUPPORT flag. This means that even though it is not mandatory, it is highly recommended.

CarePlan.careTeam refers to the CareTeam ressource and is used to describe both the organisation that delivers the interventions described in the care plan (CarePlan.careTeam:CareTeam.participant.member), and the type of delivery (FFB tilbud) (CarePlan.careTeam:CareTeam.category).

The target group (Målgruppe) for FFB is specified in the Goal.adressess attribute. Note that the primary and secondary target groups are distinguished using a ConditionRank extension. The primary target group should have rank 1, all others do not have a required rank. FFB requires a primary target group only. The target group is expressed using a FocusCondition profile. Note that only FocusConditions, where the code is actually a target group is relevant here.

CarePlan.intent, CarePlan.status and CarePlan.subject are mandatory in the FHIR CarePlan resource. It is important that the intent is set to “order”, when the interventions have been approved by municipality authorities (når bevillingen er sket). The status should, as a minimum distinguish between draft, active, revoked and completed plans. Note that the meaning of active is “ready to be acted upon”, so it does not signify that the first activities have occured.

The relevantHistory extension points to earlier significant versions of the CarePlan. Using the relevantHistory extension is recommended if changes to carePlans over time is of relevance for the use case.

CarePlan.activity.outcomeReference is used to represent assesments. Typically Assessment of needs, assessment of citizen resources, and assesment of citizen perspective is relevant, but others may be included. When it comes to of needs (støttebehovsvurdering), it may be used to represent both the initial assesment of needs, and the assesment made when terminating the CarePlan. To make explicite which activity is performed, set activity.detail.code.coding to the appropriate code e.g. effe55c7-572c-4a99-8fb4-2a9dda2f6572 “Støttebehovsvurdering”.

CarePlan:extension.municipalityCaseNumber is a relation to the municipality case (Sag). The officialCaseIdentifier uses an official http-adress and uuid to relate to a municipality case (Rammearkitektur: Sag.ID). The municipalitySpecificCaseIdentifier uses a municipality specific ID as a value, and relates to the organization that owns this caseIdentifier(Rammearkitektur Sag.Sagsnummer og Sag.ejer Sagsaktør).

Conversions between Danish information model and FHIR-profile

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.

• Differential Table
• Key Elements Table
• Snapshot Table
• Statistics/References
• All

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
status		1..1	code	[DK] indsatsforløbstatus
intent		1..1	code	[DK] indsatsforløbhensigt
category		1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
coding		0..*	Coding	[DK] indsatsforløbKategori
description	S	0..1	string	[DK] indsatsforløbBeskrivelse
subject		1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
period
start		0..1	dateTime	[DK] indsatsforløbBevillingstid
end		0..1	dateTime	[DK] indsatsforløbAfslutningstid
created		1..1	dateTime	[DK] indsatsforløbOprettelsestid
author		0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses		0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity		0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
detail
code
coding		0..*	Coding	[DK] vurderinger
activity:carePlanEvaluation		0..*	BackboneElement	Action to occur as part of plan
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
detail
code		1..1	CodeableConcept	Detail type of activity Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 95ec4535-8fe8-4296-867c-35de421794cf
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	extensible	KLCarePlanCategoryCodes

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbstatus Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	[DK] indsatsforløbhensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
category	Σ	1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
coding	Σ	0..*	Coding	[DK] indsatsforløbKategori
description	SΣ	0..1	string	[DK] indsatsforløbBeskrivelse
subject	Σ	1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
created	Σ	1..1	dateTime	[DK] indsatsforløbOprettelsestid
author	Σ	0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses	Σ	0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity	C	0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
activity:carePlanEvaluation	C	0..*	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.status	required	RequestStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	extensible	KLCarePlanCategoryCodes

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this plan
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan)	Fulfills CarePlan
replaces	Σ	0..*	Reference(CarePlan)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CarePlan)	Part of referenced CarePlan
status	?!Σ	1..1	code	[DK] indsatsforløbstatus Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	[DK] indsatsforløbhensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
category	Σ	1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	[DK] indsatsforløbKategori
text	Σ	0..1	string	Plain text representation of the concept
title	Σ	0..1	string	Human-friendly name for the care plan
description	SΣ	0..1	string	[DK] indsatsforløbBeskrivelse
subject	Σ	1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
period	Σ	0..1	Period	Time period plan covers
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatsforløbAfslutningstid
created	Σ	1..1	dateTime	[DK] indsatsforløbOprettelsestid
author	Σ	0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
contributor		0..*	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who provided the content of the care plan
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses	Σ	0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
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
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity	C	0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
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
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
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] vurderinger
text	Σ	0..1	string	Plain text representation of the concept
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
activity:carePlanEvaluation	C	0..*	BackboneElement	Action to occur as part of plan
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
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
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
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		1..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 95ec4535-8fe8-4296-867c-35de421794cf
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
note		0..*	Annotation	Comments about the plan
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
CarePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.status	required	RequestStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	extensible	KLCarePlanCategoryCodes
CarePlan.addresses.type	extensible	ResourceType
CarePlan.activity.outcomeCodeableConcept	example	CarePlanActivityOutcome
CarePlan.activity.detail.kind	required	CarePlanActivityKind
CarePlan.activity.detail.code	example	ProcedureCodes(SNOMEDCT)
CarePlan.activity.detail.reasonCode	example	SNOMEDCTClinicalFindings
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.product[x]	example	SNOMEDCTMedicationCodes
CarePlan.activity:carePlanEvaluation.outcomeCodeableConcept	example	CarePlanActivityOutcome
CarePlan.activity:carePlanEvaluation.detail.kind	required	CarePlanActivityKind
CarePlan.activity:carePlanEvaluation.detail.code	example	Pattern: 95ec4535-8fe8-4296-867c-35de421794cf
CarePlan.activity:carePlanEvaluation.detail.reasonCode	example	SNOMEDCTClinicalFindings
CarePlan.activity:carePlanEvaluation.detail.status	required	CarePlanActivityStatus
CarePlan.activity:carePlanEvaluation.detail.product[x]	example	SNOMEDCTMedicationCodes

Differential View

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
status		1..1	code	[DK] indsatsforløbstatus
intent		1..1	code	[DK] indsatsforløbhensigt
category		1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
coding		0..*	Coding	[DK] indsatsforløbKategori
description	S	0..1	string	[DK] indsatsforløbBeskrivelse
subject		1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
period
start		0..1	dateTime	[DK] indsatsforløbBevillingstid
end		0..1	dateTime	[DK] indsatsforløbAfslutningstid
created		1..1	dateTime	[DK] indsatsforløbOprettelsestid
author		0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses		0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity		0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
detail
code
coding		0..*	Coding	[DK] vurderinger
activity:carePlanEvaluation		0..*	BackboneElement	Action to occur as part of plan
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
detail
code		1..1	CodeableConcept	Detail type of activity Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 95ec4535-8fe8-4296-867c-35de421794cf
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	extensible	KLCarePlanCategoryCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbstatus Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	[DK] indsatsforløbhensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
category	Σ	1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
coding	Σ	0..*	Coding	[DK] indsatsforløbKategori
description	SΣ	0..1	string	[DK] indsatsforløbBeskrivelse
subject	Σ	1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
created	Σ	1..1	dateTime	[DK] indsatsforløbOprettelsestid
author	Σ	0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses	Σ	0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity	C	0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
activity:carePlanEvaluation	C	0..*	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
CarePlan.status	required	RequestStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	extensible	KLCarePlanCategoryCodes

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan		0..*	CarePlan	Healthcare plan for patient or group
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. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
relevantHistory		0..*	Reference(Provenance)	[DK] indsatsforløbændringshistorie URL: http://hl7.org/fhir/StructureDefinition/request-relevantHistory
municipalityCaseNumber		0..1	(Complex)	[DK] anledningDokumenteretISag URL: http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	External Ids for this plan
instantiatesCanonical	Σ	0..*	canonical(PlanDefinition | Questionnaire | Measure | ActivityDefinition | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri	Σ	0..*	uri	Instantiates external protocol or definition
basedOn	Σ	0..*	Reference(CarePlan)	Fulfills CarePlan
replaces	Σ	0..*	Reference(CarePlan)	CarePlan replaced by this CarePlan
partOf	Σ	0..*	Reference(CarePlan)	Part of referenced CarePlan
status	?!Σ	1..1	code	[DK] indsatsforløbstatus Binding: RequestStatus (required): Indicates whether the plan is currently being acted upon, represents future intentions or is now a historical record.
intent	?!Σ	1..1	code	[DK] indsatsforløbhensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan.
category	Σ	1..1	CodeableConcept	Type of plan Binding: KLIndsatsforløbTypekoder (extensible)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	0..*	Coding	[DK] indsatsforløbKategori
text	Σ	0..1	string	Plain text representation of the concept
title	Σ	0..1	string	Human-friendly name for the care plan
description	SΣ	0..1	string	[DK] indsatsforløbBeskrivelse
subject	Σ	1..1	Reference(Citizen)	[DK] indsatsforløbsubjekt
encounter	Σ	0..1	Reference(Encounter)	Encounter created as part of
period	Σ	0..1	Period	Time period plan covers
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
start	ΣC	0..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatsforløbAfslutningstid
created	Σ	1..1	dateTime	[DK] indsatsforløbOprettelsestid
author	Σ	0..1	Reference(Organization)	[DK] indsatsforløbansvarlig
contributor		0..*	Reference(Patient | Practitioner | PractitionerRole | Device | RelatedPerson | Organization | CareTeam)	Who provided the content of the care plan
careTeam		0..*	Reference(ServicePerformer)	[DK] indsatsforløbsleverandør og indsatsforløbtilbud
addresses	Σ	0..*	Reference(FocusCondition)	[DK] indsatsforløbmålgruppe
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
conditionRank		0..1	positiveInt	[DK] indsatsforløbsmålgruppeRang URL: http://fhir.kl.dk/core/StructureDefinition/ConditionRank
reference	ΣC	0..1	string	Literal reference, Relative, internal or absolute URL
type	Σ	0..1	uri	Type the reference refers to (e.g. "Patient") Binding: ResourceType (extensible): Aa resource (or, for logical models, the URI of the logical model).
identifier	Σ	0..1	Identifier	Logical reference, when literal reference is not known
display	Σ	0..1	string	Text alternative for the resource
supportingInfo		0..*	Reference(Resource)	Information considered as part of plan
Slices for goal		1..*	Reference(Goal)	Desired outcome of plan Slice: Unordered, Open by value:resolve().category
goal:fpurpose		1..1	Reference(Goal - Purpose)	[DK] indsatsforløbFormål
goal:ffbgoal		0..*	Reference(Goal - FFB Intervention)	[DK] indsatsforløbsmål
Slices for activity	C	0..*	BackboneElement	Action to occur as part of plan Slice: Unordered, Open by value:detail.code
activity:All Slices				Content/Rules for all slices
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Resource)	[DK] vurderinger
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
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
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		0..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter.
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] vurderinger
text	Σ	0..1	string	Plain text representation of the concept
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
activity:carePlanEvaluation	C	0..*	BackboneElement	Action to occur as part of plan
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
outcomeCodeableConcept		0..*	CodeableConcept	Results of the activity Binding: CarePlanActivityOutcome (example): Identifies the results of the activity.
outcomeReference		0..*	Reference(Evaluation)	Appointment, Encounter, Procedure, etc.
progress		0..*	Annotation	Comments about the activity status/progress
reference	C	0..1	Reference(Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription | RequestGroup)	Activity details defined in specific resource
detail	C	0..1	BackboneElement	In-line definition of activity
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
kind		0..1	code	Appointment | CommunicationRequest | DeviceRequest | MedicationRequest | NutritionOrder | Task | ServiceRequest | VisionPrescription Binding: CarePlanActivityKind (required): Resource types defined as part of FHIR that can be represented as in-line definitions of a care plan activity.
instantiatesCanonical		0..*	canonical(PlanDefinition | ActivityDefinition | Questionnaire | Measure | OperationDefinition)	Instantiates FHIR protocol or definition
instantiatesUri		0..*	uri	Instantiates external protocol or definition
code		1..1	CodeableConcept	Detail type of activity Binding: ProcedureCodes(SNOMEDCT) (example): Detailed description of the type of activity; e.g. What lab test, what procedure, what kind of encounter. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://fhir.kl.dk/term/CodeSystem/CareSocialCodes
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 95ec4535-8fe8-4296-867c-35de421794cf
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
reasonCode		0..*	CodeableConcept	Why activity should be done or why activity was prohibited Binding: SNOMEDCTClinicalFindings (example): Identifies why a care plan activity is needed. Can include any health condition codes as well as such concepts as "general wellness", prophylaxis, surgical preparation, etc.
reasonReference		0..*	Reference(Condition | Observation | DiagnosticReport | DocumentReference)	Why activity is needed
goal		0..*	Reference(Goal)	Goals this activity relates to
status	?!	1..1	code	not-started | scheduled | in-progress | on-hold | completed | cancelled | stopped | unknown | entered-in-error Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	Reason for current status
doNotPerform	?!	0..1	boolean	If true, activity is prohibiting action
scheduled[x]		0..1		When activity is to occur
scheduledTiming			Timing
scheduledPeriod			Period
scheduledString			string
location		0..1	Reference(Location)	Where it should happen
performer		0..*	Reference(Practitioner | PractitionerRole | Organization | RelatedPerson | Patient | CareTeam | HealthcareService | Device)	Who will be responsible?
product[x]		0..1		What is to be administered/supplied Binding: SNOMEDCTMedicationCodes (example): A product supplied or administered as part of a care plan activity.
productCodeableConcept			CodeableConcept
productReference			Reference(Medication | Substance)
dailyAmount		0..1	SimpleQuantity	How to consume/day?
quantity		0..1	SimpleQuantity	How much to administer/supply/consume
description		0..1	string	Extra info describing activity to perform
note		0..*	Annotation	Comments about the plan
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
CarePlan.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
CarePlan.status	required	RequestStatus
CarePlan.intent	required	CarePlanIntent
CarePlan.category	extensible	KLCarePlanCategoryCodes
CarePlan.addresses.type	extensible	ResourceType
CarePlan.activity.outcomeCodeableConcept	example	CarePlanActivityOutcome
CarePlan.activity.detail.kind	required	CarePlanActivityKind
CarePlan.activity.detail.code	example	ProcedureCodes(SNOMEDCT)
CarePlan.activity.detail.reasonCode	example	SNOMEDCTClinicalFindings
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.product[x]	example	SNOMEDCTMedicationCodes
CarePlan.activity:carePlanEvaluation.outcomeCodeableConcept	example	CarePlanActivityOutcome
CarePlan.activity:carePlanEvaluation.detail.kind	required	CarePlanActivityKind
CarePlan.activity:carePlanEvaluation.detail.code	example	Pattern: 95ec4535-8fe8-4296-867c-35de421794cf
CarePlan.activity:carePlanEvaluation.detail.reasonCode	example	SNOMEDCTClinicalFindings
CarePlan.activity:carePlanEvaluation.detail.status	required	CarePlanActivityStatus
CarePlan.activity:carePlanEvaluation.detail.product[x]	example	SNOMEDCTMedicationCodes

This structure is derived from CarePlan

Summary

Mandatory: 4 elements (1 nested mandatory element)
Must-Support: 1 element

Structures

This structure refers to these other structures:

• Citizen (http://fhir.kl.dk/core/StructureDefinition/KLCommonCitizen)
• Organization (http://fhir.kl.dk/core/StructureDefinition/KLCommonOrganization)
• ServicePerformer (http://fhir.kl.dk/core/StructureDefinition/KLCommonServicePerformer)
• FocusCondition (http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialFocusCondition)
• Goal - Purpose (http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialPurpose)
• Goal - FFB Intervention (http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialFFBGoal)
• Evaluation (http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialEvaluation)

Extensions

This structure refers to these extensions:

• http://hl7.org/fhir/StructureDefinition/request-relevantHistory
• http://fhir.kl.dk/core/StructureDefinition/MunicipalityCaseNumber
• http://fhir.kl.dk/core/StructureDefinition/ConditionRank

Slices

This structure defines the following Slices:

• The element CarePlan.goal is sliced based on the value of value:resolve().category
• The element CarePlan.activity is sliced based on the value of value:detail.code