Scope and usage

FollowUpObservation is used for documenting the result of a follow-up procedure, as documented by FSIII. Follow-ups are documented using this profile, whether they are documented by suppliers during an intervention, or documented by autorities, at planned follow-ups.

The profile has the Follow-up result in Observation.valueCodeableConcept.coding

The ObservationCode is mandatory, and fixed to a specific SNOMED CT code that signifies that this is an evaluation of a care plan (evaluering af indsats i bred forstand).

The status is in this implementation guide should either be final or entered-in-error.

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 Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
identifier		0..0
basedOn		0..0
partOf		0..0
status		1..1	code	[DK] opfølgningsstatus
category		0..0
code
coding		1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
subject		0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus		1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
encounter		0..0
effective[x]		1..1	dateTime	[DK] opfølgningstid
issued		0..0
performer		0..0
value[x]		1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
dataAbsentReason		0..0
interpretation		0..0
note		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
referenceRange		0..0
hasMember		0..0
derivedFrom		0..0
component		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.value[x]	required	KLFollowUpCodesFSIII

Constraints

Id	Grade	Path(s)	Details	Requirements
gateway-care-follow-up-1	error	Observation	A follow-up observation resource shall have status final or entered-in-error : status = 'final' or status = 'entered-in-error'

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsstatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
coding	Σ	1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
subject	Σ	0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus	Σ	1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
effective[x]	Σ	1..1	dateTime	[DK] opfølgningstid
value[x]	ΣC	1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.status	required	ObservationStatus
Observation.code	example	LOINCCodes (a valid code from LOINC)
Observation.value[x]	required	KLFollowUpCodesFSIII
Observation.component.code	example	LOINCCodes (a valid code from LOINC)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gateway-care-follow-up-1	error	Observation	A follow-up observation resource shall have status final or entered-in-error : status = 'final' or status = 'entered-in-error'
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsstatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
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://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus	Σ	1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
effective[x]	Σ	1..1	dateTime	[DK] opfølgningstid
value[x]	ΣC	1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.code	example	LOINCCodes (a valid code from LOINC)
Observation.value[x]	required	KLFollowUpCodesFSIII
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

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

Differential View

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
identifier		0..0
basedOn		0..0
partOf		0..0
status		1..1	code	[DK] opfølgningsstatus
category		0..0
code
coding		1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
subject		0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus		1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
encounter		0..0
effective[x]		1..1	dateTime	[DK] opfølgningstid
issued		0..0
performer		0..0
value[x]		1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
dataAbsentReason		0..0
interpretation		0..0
note		0..0
bodySite		0..0
method		0..0
specimen		0..0
device		0..0
referenceRange		0..0
hasMember		0..0
derivedFrom		0..0
component		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.value[x]	required	KLFollowUpCodesFSIII

Constraints

Id	Grade	Path(s)	Details	Requirements
gateway-care-follow-up-1	error	Observation	A follow-up observation resource shall have status final or entered-in-error : status = 'final' or status = 'entered-in-error'

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsstatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
coding	Σ	1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
subject	Σ	0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus	Σ	1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
effective[x]	Σ	1..1	dateTime	[DK] opfølgningstid
value[x]	ΣC	1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.status	required	ObservationStatus
Observation.code	example	LOINCCodes (a valid code from LOINC)
Observation.value[x]	required	KLFollowUpCodesFSIII
Observation.component.code	example	LOINCCodes (a valid code from LOINC)

Constraints

Id	Grade	Path(s)	Details	Requirements
dom-2	error	Observation	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	Observation	If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource or SHALL refer to the containing resource : contained.where((('#'+id in (%resource.descendants().reference | %resource.descendants().as(canonical) | %resource.descendants().as(uri) | %resource.descendants().as(url))) or descendants().where(reference = '#').exists() or descendants().where(as(canonical) = '#').exists() or descendants().where(as(canonical) = '#').exists()).not()).trace('unmatched', id).empty()
dom-4	error	Observation	If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated : contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
dom-5	error	Observation	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	Observation	A resource should have narrative for robust management : text.`div`.exists()
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()
gateway-care-follow-up-1	error	Observation	A follow-up observation resource shall have status final or entered-in-error : status = 'final' or status = 'entered-in-error'
obs-6	error	Observation	dataAbsentReason SHALL only be present if Observation.value[x] is not present : dataAbsentReason.empty() or value.empty()
obs-7	error	Observation	If Observation.code is the same as an Observation.component.code then the value element associated with the code SHALL NOT be present : value.empty() or component.code.where(coding.intersect(%resource.code.coding).exists()).empty()

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions gateway-care-follow-up-1: A follow-up observation resource shall have status final or entered-in-error
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
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsstatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations Slice: Unordered, Open by value:url
coding	Σ	1..1	Coding	Code defined by a terminology system Required Pattern: At least the following
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://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(CareCitizen) {b}	[DK] opfølgningsubjekt
focus	Σ	1..*	Reference(CareCondition | CarePlannedIntervention)	What the observation is about, when it is not about the subject of record
effective[x]	Σ	1..1	dateTime	[DK] opfølgningstid
value[x]	ΣC	1..1	CodeableConcept	Actual result Binding: KLOpfølgningKoderFSIII (required)
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.code	example	LOINCCodes (a valid code from LOINC)
Observation.value[x]	required	KLFollowUpCodesFSIII
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

Constraints

Id	Grade	Path(s)	Details	Requirements
ele-1	error	**ALL** elements	All FHIR elements must have a @value or children : hasValue() or (children().count() > id.count())
ext-1	error	**ALL** extensions	Must have either extensions or value[x], not both : extension.exists() != value.exists()

This structure is derived from Observation

Summary

Mandatory: 4 elements
Prohibited: 18 elements

Structures

This structure refers to these other structures:

• CareCitizen (http://fhir.kl.dk/gateway/StructureDefinition/klgateway-care-citizen)
• CareCondition (http://fhir.kl.dk/gateway/StructureDefinition/klgateway-care-condition)
• CarePlannedIntervention (http://fhir.kl.dk/gateway/StructureDefinition/klgateway-care-planned-intervention)