Overall CarePlan for Danish municipalities, for individual plans regarding social care, and health act §140 and §119

Citizen demographics, as expressed by dk-core

Citizens own observation of performance level (udførelse) or importance level (betydning) as defined by FSIII

Documentation for completed inteventions (activities related to one and only one encounter) in Danish municipalities

Detailed information about conditions in Danish municiplities health, social and elderly care.

Encounters used for care and social services in Danish municipalities.

Professional evaluation on citizen status based on gathered information, conditions, observations and citizen preferences used in Danish municipalities

Conditions which may be used to express the focus of an intervention or the problem of a citizen in Danish municipalities. Mostly used for cross sector use cases.

Follow-up results used in Danish municipalities

Goal as defined in Danish municipalities

FFB goal as defined by FFB in Danish municipalities

Purpose as defined by FFB in Danish municipalities

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

Matter or area of interest in relation to the care of the citizen, as used in Danish municipalities (Oplysning/Område/Tema)

Observations and measurements performed in Danish municipalities

Organisation as expressed by Danish municipalities.

Planned interventions (indsats/ydelse) in Danish Municipalities

Practitioners as expressed by dk-core.

Service performing CareTeam as expressed by Danish municipalities.

Referals/requests used in Danish municipalities

A reference to a ServiceRequest. Used to connect an event resource with the order that warranted it

Extension for the last date a condition was confirmed valid with its current clinical- and verification status, stage and severity, typically the last performed follow-up

The rank of a condition. Used for event-resources that refer to conditions that are ranked.

Event history, pointing to earlier significant versions of this resource. Comparable to http://hl7.org/fhir/StructureDefinition/event-eventHistory, working for Conditions

Extension for pointing to previous and planned follow up encounters for a condition

Extension for pointing to who’s perspective the matter-of-interest is comming from

Extension for municipality case numbers

Extension for pointing to type of organisation/person that requests a service from the municipality

Extension for describing whether the citizen knows about the request/referal

Importance level codes (Betydning), as evaluated by the citizen

Codes for citizens knowledge of referal/request as defined by FFB

Observation codes for citizens own observations as defined by FSIII

Performance and Importance level codes, as evaluated by the citizen

Prevention and health promotion interventions as defined by FSIII

Prevention areas (observation codes), used for documentation within prevention and health promotion

Severities related to conditions in FFB (funktionsevneniveau)

Severities related to conditions in FSIII home care (funktionsniveau)

Generel information codes (observations) as defined by FSIII

Type of service requesters as defined by FSIII

Home Care Interventions as described by FSIII

Observation codes for the five home care areas as defined by FSIII

Interventions as described by FSIII and FFB

Interventions as described by FSIII

Codes for constraining the CarePlan category

Codes that identify who’s perspective the matter-of-interest is comming from

Codes that indicate whether an intervention had complications or not

Encounter types in Danish municipality health, social and elderly care (note that these are specific to this model, they are not replicas of a municipality terminology service)

Target groups as defined by FFB

Codes used to distinguish different kinds of goals

Change values for goals (måltype). Express the target value for change of a condition

Change values for goals in FFB (FFB måltype). Express the target value for change of an activity or participation condition

Change values for goals in FSIII (FSIII måltype). Express the target value for change of a health condition or funtional condition

SNOMED CT and NPU codes used in Danish municipalities

Follow-up codes used in FFB

Follow-up codes used in FSIII

Follow-up codes used in Danish municipalities

Matter of interes values to support when no observations have been made

Information codes from FSIII and FFB (Område, Tema, Generelle oplysninger)

Codes that identify valid items in an investigation in Danish municipalities

Codes used to specify which kind of information gathering is conducted

Types of services that the Danish municipalities provide which is covered by FSIII and FFB

Needs assesment codes as defined in FFB

Severities related to conditions

Nursing interventions as described by FSIII

Observation codes for the 12 nursing areas as defined by FSIII

FFB Themes

Social service (tilbud) as defined by FFB

Danish municipality FFB condition codes for Activities and Participation

Danish municipality home care condition codes (funktionsevnetilstande)

Danish municipality nursing condition codes

Conditions and target groups as defined by FFB

Danish municipality FFB condition codes for body functions and structures

Danish municipality condition codes

Danish municipality FFB condition codes

Danish municipality Prevention condition codes

Danish municipality FSIII condition codes

Danish municipality theraphy condition codes

Danish municipality FFB condition codes for Environmental Factors

Training interventions as defined by FSIII

Theraphy areas (observation codes), used for documentation within physical training, physiotheraphy and occupational theraphy in Danish Municipalities as defined by FSIII

Target measure code, that determines whether the target is expressed as a severity, change value or using another observation

Performance level codes (Udførelse), as evaluated by the citizen

Codes used to distinguish different kinds of evaluations

SNOMED CT codes used to distinguish different kinds of evaluations

social interventions (ydelser) as defined by FFB

Eksempel på medarbejderen Abraham fra akutsygeplejen

Levering af indsats til Mark vedr. undersøgelser og måling af værdier efter henvisning fra læge vedr. akut sygepleje

Almindeligt længerevarende botilbud på Sommergaarden

Borger Andreas

Andreas social indsats vedr. almen botilbud

Delmål for Andreas

Indsatsformål for Andreas

Indsatsformål for Andreas ifm. at han skifter fra midlertidig til almen botilbud

Indsatsmål for Andreas

Andreas social indsats vedr. midlertidigt ophold

Mål og ønsker for Andreas

Andreas’ målgruppe

Andreas notat vedr. det at varetage egen sundhed, når tilstanden ikke er kendt

Indsatsmål for Andreas, som dokumenteret efter opfølgningstidspunktet (Tilstanden ikke opdateret, fordi implementation guiden ikke versionshåndterer)

Borgeren Andreas der har udfordringer med rengøring

Borgeren Andreas der har udfordringer med rengøring, og en udfører fra Hvidbjerghus, der laver et notat

Eksempel på opfølgningsresultatet revisitation

Visitationen vurderer at Andreas har et højt støttebehov

Eksempel på pårørende Andreas’ mor Gitte

Andreas’ ydelse daglige opgaver

Andreas’ ydelse sociale relationer

Eksempel på medarbejderen Anne fra botilbudet Hvidbjerghus

Eksempel på medarbejderen Birte fra visitationen i Morsø

Borgeren Ejnar

Botilbudet Hvidbjerghus som defineret af https://findsocialetilbud.dk/sociale-tilbud/botilbuddet-hvidbjerghus, og SOR

Botilbudet Sommergaarden, som er et fiktivt eksempel

Example of the citizen, Mark, who has a pressure ulcer

Ejner opfølgningsresultat

Ejnars tilstand:Problemer med misbrug

Opdatering til version 2 af Ejnars tilstand:Problemer med misbrug

Opdatering til version 3 af Ejnars tilstand:Problemer med misbrug, hvor tilstanden afsluttes

Notat vedr. psykosociale forhold, som beskrevet af hjemmesygeplejen ifm sygeplejefaglig udredning

Ejnars udførte opfølgning, der er en opdatering af Ejnars planlagte opfølgning

Ejnar er i sorg pga. ægtefælles død. Dette anvendes i eksemplet som bagvedliggende årsag til misbrug

Ejnars planlagte opfølgning

Eksempel på medarbejderen Hanne fra visitationen i Aalborg

Henvendelse fra mor vedr. social indsats

Henvisning fra læge vedr. akut sygepleje

Henvisning fra læge vedr. akut sygepleje

Hjemmesygepleje – visitation –hjemmehjælp i Sønderborg kommune som defineret af SOR

Områdenotat vedr. hud og slimhinder for Mark

Intern henvisning i hjemmeplejen, efter en opfølgning der viste behov for revisitation

Borger Judith

En diagnose som registreret i kommunen, hvor Hanne fra Aalborg har registreret informationen fra lægen Marianne, som fx kunne komme fra diabetescenteret på hospitalet

Forventet tilstand for Judith, der har et mobilitetsproblem

Borgeren judith der har udfordringer med at gå

Judiths vurdering af egen evne til at gå

Eksempel på medarbejderen Kristina fra Voksensocialområdet i Holstebro

Praktisernede læge i Hasseris, som defineret af SOR

Borger Mads

Eksempel på læge Marianne

Borger Mark

Forventet tilstand for Mark, der har et tryksårsproblem

Eksempel på Marks helhedvurdering, som er opdateret efter der er lavet en sygeplejefaglig udredning

FSIII indsatsmål for Mark, der har et tryksårsproblem

Kontakt hvor der leveres en akutindsats til Mark

Kontakt hvor der leveres en sårbehandling til Mark efter planen

Kontakt hvor der udføres en sygeplejefaglig udredning på Mark

Mark’s planlagte opfølgning, med periode.start fremtidigt

Borgeren Marks sygeplejefaglige udredning

Observation af Marks blodsukker

Observation af Marks diastoliske blodtryk (OBS: Mere specifik profil for blodtryk findes i værktøjsprojektet, dette er udelukkende et eksempel for denne implememnattion guide)

Eksempel på opfølgningsresultatet revisitation

Observation af Marks puls (OBS: Mere specifik profil for puls findes i værktøjsprojektet, dette er udelukkende et eksempel, dette er udelukkende et eksempel for denne implememnattion guide)

Mark’s planlagte tryksårsindsats, med én tilknyttet kontakt

Mads’ mentale funktioner, med perspektivet, at det er oplysninger af andre

Mads’ mentale funktioner, med perspektivet, at det er oplysninger fra borger

Midlertidigt ophold efter servicelovens §107 på Hvidhjerghus

Områdenotat vedr. Judiths mobilitet

Eksempel på medarbejderen Natasja fra sygeplejen

Ekstraoplysninger vedr. dokumentationsarbejdsgang og ansvar for henvendelse fra mor vedr. social indsats

Ekstraoplysninger vedr. dokumentationsarbejdsgang og ansvar for henvisning fra læge vedr. akut sygepleje

Områdenotat vedr. respiration og cirkulation for Mark

Social og Sundhed, Morsø Kommune, som defineret af SOR

Sundheds- og kulturforvaltningen, Aalborg Kommune, som defineret af SOR