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
Official URL: http://fhir.kl.dk/core/StructureDefinition/KLCommonCareSocialObservation | Version: 1.2.0 | |||
Active as of 2023-06-07 | Computable Name: KLCommonCareSocialObservation |
Observations and measurements performed in Danish municipalities
KLCommonCareSocialObservation is used to document results of activities where a property of a citizen is observed or meassured. This means that both FSIII meassurements (målinger) and FSIII observations (observationer) may be captured using this resource. FFB does not specify observations per se, but could use this resource if a need arise. The use of this resource should not be confused with what FFB defines as professional notes/observations (faglige notater/observationer), which are notes made by service providers during an intervention. Use the CommonCareSocialCondition resource instead.
KLCommonCareSocialObservation is loosely modelled. Special care should be taken when choosing the Observation.code.coding, which is mandatory. It is currently bound to an extensible set of SNOMED CT codes. If extending the set is nessesary for a use case, it is recommended that a SNOMED CT observation code is chosen, and that you report which code you use to Local Government Denmark (Kommunernes Landsforening). Be aware that more specific profiles are also designed. Browse this implementation guide, and the Tooling implementation guide for specific observation profiles before using this general one.
The CommonCareSocialObservation may be linked to the plan, proposal or order that autorized the observation. Use the basedOn attribute to link to CommonCareSocialPlannedIntervention, CommonCareSocialServiceRequest or CommonCareSocialCarePlan.
Notice that the status-attribute is mandatory. For normal use, just set to “final”, if data is missing or another problem has occured, follow the FHIR guidance to populate the field correctly.
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 |
---|---|---|
observationskode | Klasse som udtrykker, hvad der observeres. | Observation.code.coding |
observationsresultat | Resultatet af observationen. | Observation.value[x] |
observationsenhed | Enheden på observationsresultatet, hvis denne er kvantitativ. | Observation.valueQuantity.unit |
observationssubjekt | Den borger, for hvem der er foretaget en observation. | Observation.subject |
observationskontakt | Den kontakt, hvor observationen er foretaget. | Observation.encounter |
observationsansvarlig | Den der er ansvarlig for observationen. | Observation.performer |
observationBaseretPå | Indsats, indsatsforløb eller henvisning som denne observation er del af udmøntningen af | Observation.basedOn |
observationstid | Tidspunkt for observationen. | Observation.effective |
observationsstatus | Klasse der udtrykker, hvor i sin proces, observationen 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(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå | |
status | 1..1 | code | [DK] observationsstatus | |
code | 1..1 | CodeableConcept | Type of observation (code / type) Binding: KLObservationskoder (extensible) | |
coding | 0..* | Coding | [DK] observationskode | |
subject | 0..1 | Reference(Citizen) | [DK] observationssubjekt | |
encounter | 0..1 | Reference(Encounter) | [DK] observationskontakt | |
effective[x] | 0..1 | dateTime, Period, Timing, instant | [DK] observationstid | |
performer | 0..* | Reference(Practioner) | [DK] observationsansvarlig | |
value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | [DK] observationsresultat | |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code | extensible | KLObservationCodes |
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(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå |
status | ?!Σ | 1..1 | code | [DK] observationsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: KLObservationskoder (extensible) |
coding | Σ | 0..* | Coding | [DK] observationskode |
subject | Σ | 0..1 | Reference(Citizen) | [DK] observationssubjekt |
encounter | Σ | 0..1 | Reference(Encounter) | [DK] observationskontakt |
effective[x] | Σ | 0..1 | [DK] observationstid | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
performer | Σ | 0..* | Reference(Practioner) | [DK] observationsansvarlig |
value[x] | ΣC | 0..1 | [DK] observationsresultat | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.code | extensible | KLObservationCodes |
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(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | [DK] observationsstatus 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 | Type of observation (code / type) Binding: KLObservationskoder (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] observationskode | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | Σ | 0..1 | Reference(Citizen) | [DK] observationssubjekt | ||||
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] observationskontakt | ||||
effective[x] | Σ | 0..1 | [DK] observationstid | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practioner) | [DK] observationsansvarlig | ||||
value[x] | ΣC | 0..1 | [DK] observationsresultat | |||||
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 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 | extensible | KLObservationCodes | ||||
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
Structures
This structure refers to these other structures:
Differential View
This structure is derived from Observation
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Observation | 0..* | Observation | Measurements and simple assertions | |
basedOn | 0..* | Reference(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå | |
status | 1..1 | code | [DK] observationsstatus | |
code | 1..1 | CodeableConcept | Type of observation (code / type) Binding: KLObservationskoder (extensible) | |
coding | 0..* | Coding | [DK] observationskode | |
subject | 0..1 | Reference(Citizen) | [DK] observationssubjekt | |
encounter | 0..1 | Reference(Encounter) | [DK] observationskontakt | |
effective[x] | 0..1 | dateTime, Period, Timing, instant | [DK] observationstid | |
performer | 0..* | Reference(Practioner) | [DK] observationsansvarlig | |
value[x] | 0..1 | Quantity, CodeableConcept, string, boolean, integer, Range, Ratio, SampledData, time, dateTime, Period | [DK] observationsresultat | |
Documentation for this format |
Path | Conformance | ValueSet |
Observation.code | extensible | KLObservationCodes |
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(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå |
status | ?!Σ | 1..1 | code | [DK] observationsstatus Binding: ObservationStatus (required): Codes providing the status of an observation. |
code | Σ | 1..1 | CodeableConcept | Type of observation (code / type) Binding: KLObservationskoder (extensible) |
coding | Σ | 0..* | Coding | [DK] observationskode |
subject | Σ | 0..1 | Reference(Citizen) | [DK] observationssubjekt |
encounter | Σ | 0..1 | Reference(Encounter) | [DK] observationskontakt |
effective[x] | Σ | 0..1 | [DK] observationstid | |
effectiveDateTime | dateTime | |||
effectivePeriod | Period | |||
effectiveTiming | Timing | |||
effectiveInstant | instant | |||
performer | Σ | 0..* | Reference(Practioner) | [DK] observationsansvarlig |
value[x] | ΣC | 0..1 | [DK] observationsresultat | |
valueQuantity | Quantity | |||
valueCodeableConcept | CodeableConcept | |||
valueString | string | |||
valueBoolean | boolean | |||
valueInteger | integer | |||
valueRange | Range | |||
valueRatio | Ratio | |||
valueSampledData | SampledData | |||
valueTime | time | |||
valueDateTime | dateTime | |||
valuePeriod | Period | |||
Documentation for this format |
Path | Conformance | ValueSet |
Observation.status | required | ObservationStatus |
Observation.code | extensible | KLObservationCodes |
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(PlannedIntervention | ServiceRequest | CarePlan) | [DK] observationBaseretPå | ||||
partOf | Σ | 0..* | Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy) | Part of referenced event | ||||
status | ?!Σ | 1..1 | code | [DK] observationsstatus 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 | Type of observation (code / type) Binding: KLObservationskoder (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] observationskode | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
subject | Σ | 0..1 | Reference(Citizen) | [DK] observationssubjekt | ||||
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] observationskontakt | ||||
effective[x] | Σ | 0..1 | [DK] observationstid | |||||
effectiveDateTime | dateTime | |||||||
effectivePeriod | Period | |||||||
effectiveTiming | Timing | |||||||
effectiveInstant | instant | |||||||
issued | Σ | 0..1 | instant | Date/Time this version was made available | ||||
performer | Σ | 0..* | Reference(Practioner) | [DK] observationsansvarlig | ||||
value[x] | ΣC | 0..1 | [DK] observationsresultat | |||||
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 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 | extensible | KLObservationCodes | ||||
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
Structures
This structure refers to these other structures:
Other representations of profile: CSV, Excel, Schematron