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. For a full list of available versions, see the Directory of published versions

Resource Profile: InformationGathering

Official URL: http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialInformationGathering Version: 1.2.0
Active as of 2023-06-07 Computable Name: KLCommonCareSocialInformationGathering

Information gathering resource used to group all the information collected in a clinical process such af a nursing status, a functional ability evaluation or a social paedagogical review

Scope and usage

The CommonCareSocialInformationGathering may be instatiated, whenever an information gathering activity occur. The InformationGathering-profile groups data from of information gathering process e.g. therapeutic examination and nursing statuses (therapeutisk udredning og sygeplejefaglig udredning). The full list of supported information gathering types are expressed as a ValueSet for ClinicalImpression.code.coding

The result of an information gathering is:

  • “information”, which reference KLCommonCareSocialMatterOfInterest, and is structured according to FSIII area codes, FFB general information codes or FFB theme codes. Use ClinicalImpression.investigation.code.coding and ClinicalImpression.investigation.item
  • Conditions, which reference KLCommonCareSocialCondition, and is structured according to FSIII conditions or FFB conditions/sub-themes. Use ClinicalImpression.finding.itemReference, and
  • Evaluations, which reference KLCommonCareSocialEvaluation. In the FSIII specification, the evaluation (FSIII helhedsvurdering), is not the conclusion of information gathering. I.e. this attribute should not reference it. ClinicalImpression.investigation.code.coding and ClinicalImpression.investigation.item

In Danish Municipalities, some information gathering procedures may strech more than one encounter. In these cases, you only have the opportunity to document the latest time and reference the latest encounter. Use ClinicalImpression.effectiveDateTime, and ClinicalImpression.encounter. If more is needed, look into the use af FHIR Provenance.

Information gathering is often the first activity after a request or referal to the municipality. To show what initiated the informationGathering, a ServiceRequest may be referenced in ClinicalImpression:extension.basedOnServiceRequest

ClinicalImpression.status is mandatory valid values are “in-progress”, “completed” and “entered-in-error”. Use the code “in-progress” if the information gathering activity stated by ClinicalImpression.code.coding is started, but not finished.

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 specificere hvilke af FHIR-profilens atributter der skal bruges til specifikation af indholdet

FKI-attribut Definition FHIR
oplysningsaktivitetstype Den type af oplysningsaktivitet der udføres ClinicalImpression.code.coding
oplysningsaktivitetsubjekt Den borger som oplysningerne vedrører ClinicalImpression.subject
oplysningsaktivitetsudfører Den fagperson, der udfører oplysningsaktiviteten ClinicalImpression.assessor
oplysningsaktivitetstid Det seneste tidspunkt hvor oplysningsaktiviteten fandt sted ClinicalImpression.effectiveDateTime
oplysningsaktivitetskontakt Den seneste kontakt hvor oplysningsaktiviteten fandt sted ClinicalImpression.encounter
oplysningsaktivitetsordre Den henvendelse eller henvisning der er grunden til at oplysningsaktiviteten finder sted ClinicalImpression:extension.basedOnServiceRequest
oplysningsaktivitetsObservationstype Klasse, der angiver om de tilknyttede observationer er oplysninger eller vurderinger. ClinicalImpression.investigation.code.coding
OplysningsaktivitetsOmråde Oplysninger organiseret under et fagligt område eller tema ClinicalImpression.investigation.item
oplysningsaktivitetsKonklusion Vurdering, der er konklusion på oplysningsaktiviteten. ClinicalImpression.investigation.item
oplysningsaktivitetsTilstand Tilstand, der er udredt ifm oplysningsaktiviteten. ClinicalImpression.finding.itemReference
oplysningsaktivitetsstatus Klasse der udtrykker, hvor i sin proces, oplysningsaktiviteten er. ClinicalImpression.status

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... status 1..1code[DK] oplysningsaktivitetsstatus
.... coding 0..*Coding[DK] oplysningsaktivitetstype
... subject 1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter 0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] 0..1dateTime[DK] oplysningsaktivitetstid
... assessor 0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører
... investigation
.... code 1..1CodeableConceptA name/code for the set
Binding: KLOplysningsaktivitetsOgVurderingskoder (required)
..... coding 0..*Coding[DK] oplysningsaktivitetsObservationstype
.... item 0..*Reference(MatterOfInterest | Evaluation)[DK] oplysningsaktivitetsKonklusion
... finding
.... itemReference 0..1Reference(Condition)[DK] oplysningsaktivitetsTilstand

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes
ClinicalImpression.investigation.coderequiredKLInformationGatheringInvestigationCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... extension 0..0
.... url 1..1uri"http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest"
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... status ?!Σ1..1code[DK] oplysningsaktivitetsstatus
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... code Σ0..1CodeableConceptKind of assessment performed
Binding: KLOplysningsaktivitetsTypeKoder (required)
.... coding Σ0..*Coding[DK] oplysningsaktivitetstype
... subject Σ1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter Σ0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] Σ0..1dateTime[DK] oplysningsaktivitetstid
... assessor Σ0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest"
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1code[DK] oplysningsaktivitetsstatus
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code Σ0..1CodeableConceptKind of assessment performed
Binding: KLOplysningsaktivitetsTypeKoder (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] oplysningsaktivitetstype
.... text Σ0..1stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter Σ0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] Σ0..1dateTime[DK] oplysningsaktivitetstid
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: KLOplysningsaktivitetsOgVurderingskoder (required)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*Coding[DK] oplysningsaktivitetsObservationstype
..... text Σ0..1stringPlain text representation of the concept
.... item 0..*Reference(MatterOfInterest | Evaluation)[DK] oplysningsaktivitetsKonklusion
... protocol 0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition)[DK] oplysningsaktivitetsTilstand
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.statusReasonexample
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes
ClinicalImpression.investigation.coderequiredKLInformationGatheringInvestigationCodes
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis

Differential View

This structure is derived from ClinicalImpression

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... status 1..1code[DK] oplysningsaktivitetsstatus
.... coding 0..*Coding[DK] oplysningsaktivitetstype
... subject 1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter 0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] 0..1dateTime[DK] oplysningsaktivitetstid
... assessor 0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører
... investigation
.... code 1..1CodeableConceptA name/code for the set
Binding: KLOplysningsaktivitetsOgVurderingskoder (required)
..... coding 0..*Coding[DK] oplysningsaktivitetsObservationstype
.... item 0..*Reference(MatterOfInterest | Evaluation)[DK] oplysningsaktivitetsKonklusion
... finding
.... itemReference 0..1Reference(Condition)[DK] oplysningsaktivitetsTilstand

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes
ClinicalImpression.investigation.coderequiredKLInformationGatheringInvestigationCodes

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... extension 0..0
.... url 1..1uri"http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest"
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... status ?!Σ1..1code[DK] oplysningsaktivitetsstatus
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... code Σ0..1CodeableConceptKind of assessment performed
Binding: KLOplysningsaktivitetsTypeKoder (required)
.... coding Σ0..*Coding[DK] oplysningsaktivitetstype
... subject Σ1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter Σ0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] Σ0..1dateTime[DK] oplysningsaktivitetstid
... assessor Σ0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. ClinicalImpression 0..*ClinicalImpressionA clinical assessment performed when planning treatments and management strategies for a patient
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... Slices for extension 0..*ExtensionExtension
Slice: Unordered, Open by value:url
... basedOnServiceRequest 0..1Reference(ServiceRequest)[DK] oplysningsaktivitetsordre
URL: http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..0
.... url 1..1uri"http://fhir.kl.dk/core/StructureDefinition/BasedOnServiceRequest"
.... value[x] 1..1Reference(ServiceRequest)Value of extension
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness identifier
... status ?!Σ1..1code[DK] oplysningsaktivitetsstatus
Binding: ClinicalImpressionStatus (required): The workflow state of a clinical impression.

... statusReason 0..1CodeableConceptReason for current status
Binding: (unbound) (example): Codes identifying the reason for the current state of a clinical impression.

... code Σ0..1CodeableConceptKind of assessment performed
Binding: KLOplysningsaktivitetsTypeKoder (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] oplysningsaktivitetstype
.... text Σ0..1stringPlain text representation of the concept
... description Σ0..1stringWhy/how the assessment was performed
... subject Σ1..1Reference(Citizen)[DK] oplysningsaktivitetsubjekt
... encounter Σ0..1Reference(Encounter)[DK] oplysningsaktivitetskontakt
... effective[x] Σ0..1dateTime[DK] oplysningsaktivitetstid
... date Σ0..1dateTimeWhen the assessment was documented
... assessor Σ0..1Reference(Practioner)[DK] oplysningsaktivitetsudfører
... previous 0..1Reference(ClinicalImpression)Reference to last assessment
... problem Σ0..*Reference(Condition | AllergyIntolerance)Relevant impressions of patient state
... investigation 0..*BackboneElementOne or more sets of investigations (signs, symptoms, etc.)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code 1..1CodeableConceptA name/code for the set
Binding: KLOplysningsaktivitetsOgVurderingskoder (required)
..... id 0..1stringUnique id for inter-element referencing
..... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
..... coding Σ0..*Coding[DK] oplysningsaktivitetsObservationstype
..... text Σ0..1stringPlain text representation of the concept
.... item 0..*Reference(MatterOfInterest | Evaluation)[DK] oplysningsaktivitetsKonklusion
... protocol 0..*uriClinical Protocol followed
... summary 0..1stringSummary of the assessment
... finding 0..*BackboneElementPossible or likely findings and diagnoses
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... itemCodeableConcept 0..1CodeableConceptWhat was found
Binding: Condition/Problem/DiagnosisCodes (example): Identification of the Condition or diagnosis.

.... itemReference 0..1Reference(Condition)[DK] oplysningsaktivitetsTilstand
.... basis 0..1stringWhich investigations support finding
... prognosisCodeableConcept 0..*CodeableConceptEstimate of likely outcome
Binding: ClinicalImpressionPrognosis (example): Prognosis or outlook findings.


... prognosisReference 0..*Reference(RiskAssessment)RiskAssessment expressing likely outcome
... supportingInfo 0..*Reference(Resource)Information supporting the clinical impression
... note 0..*AnnotationComments made about the ClinicalImpression

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet
ClinicalImpression.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
ClinicalImpression.statusrequiredClinicalImpressionStatus
ClinicalImpression.statusReasonexample
ClinicalImpression.coderequiredKLInformationGatheringTypeCodes
ClinicalImpression.investigation.coderequiredKLInformationGatheringInvestigationCodes
ClinicalImpression.finding.itemCodeableConceptexampleCondition/Problem/DiagnosisCodes
ClinicalImpression.prognosisCodeableConceptexampleClinicalImpressionPrognosis

 

Other representations of profile: CSV, Excel, Schematron