Scope and usage

The CarePlan for §140 is used whenever a rehabilitation care pathway is planned for a citizen in Danish municipalities. Care pathway or plan is a way to describe when a number of planned interventions are delivered together with a common schedule.

The two types of plan in §140 are ‘Opfølgningsforløb efter §140’ and ‘Interventionsforløb efter §140’ and one of these two codes should be documented in CarePlan.category.

It is important to distiguish correctly between the dates and times stated in the model. CarePlan.period.start is when the CarePlan was authorized (bevillingstid). The planned end-date is CarePlan.period.end, unless the date has already occured and the status is ‘completed’, then it is the actual end-date. Notice that end-date is not mandatory to report. All dates may be repported with or without time of day.

CarePlan.status and CarePlan.intent are mandatory in the FHIR CarePlan resource. CarePlan.intent is always ‘plan’ in this implementation guide. CarePlan status should at least distiguish between ‘unknown’ and ‘entered-in-error’, but the actual status of the care plan may also be reported. Note that the meaning of ‘active’ is “ready to be acted upon”, so it does not signify that the first activity has occured.

CarePlan.activity.detail.status is also mandatory, and all the statuses in the FHIR ValueSet may be used. It is recommended not to use ‘entered-in-error’ - if the CarePlan is entered-in-error use CarePlan.status. To get the needed data-quality, the detail-status should at least distinguish between ‘unknown’ and ‘cancelled’. Although it is better to use the appropriate FHIR-statuses, ‘unknown’ is permitted from the time where the care plan occurs in the record until its completion. ‘Cancelled’ (or ‘stopped’) are mandatory, if an care plan is cancelled. It is mandatory to report cancelled care plans, so that the reason for the cancellation can inform the dataset. This is done using CarePlan.activity.detail.statusReason, and a set of codes that represents different reasons for the cancellation. The codes are as follows:

• ‘Hændelse medfører ophør’
• ‘Ikke yderligere behov (borger-vurderet)’
• ‘Ikke yderligere behov (fagperson-vurderet)’
• ‘Borger har ikke henvendt sig eller er udeblevet’
• ‘Aktivt fravalg’
  • ‘Aktivt fravalg pga. anden sygdom’
  • ‘Aktivt fravalg pga. økonomi ifm. transport’
  • ‘Aktivt fravalg pga. logisik ifm. transport’
  • ‘Aktivt fravalg pga. anden træning’

It is premitted to use the code ‘Aktivt fravalg’ for reporting, but the more detailed codes, though not mandatory, provides for a more nuanced dataset.

CarePlan.subject references the citizen. CarePlan.activity.detail.performer is the organisation that carries out the care plan (leverandør).

The CarePlan.extension[basedOnServiceRequest] points to the ServiceRequest (GGOP) which was the starting point for the care plan. It may happen that an care plan has two ServiceRequests as a starting point. Imagine that a citizen has gotten a hip replacement, has been dicharges from the hospital and has started rehabilitation. Then the citizen falls and gets re-admitted to the hospital. At discharge, a new ServiceRequest is send, but because the damage was small, the municipality care plan preceeds as planned. In this case, change CarePlan.extension[basedOnServiceRequest] from the later, to the newer ServiceRequest. If the patient is admitted for a longer time, so that the care plan changes i.e. the citizen starts over in group based training, cancel the ealier care plan, and start a new one pertaining to the new ServiceRequest. If two different ServiceRequests results in two different care plans (e.g. hip replacement rehabilitation and shoulder rehabilitation), all serviceRequests and care plans exists in parallel, but should reference each other correctly (e.g shoulder GGOP to shoulder training and hip GGOP to mobility training).

Different reasons for changing a CarePlan may exist, and here we provide guidance for how it should be reported:

• Errors should be corrected by reporting the same CarePlan again with the entered-in-error status. And reporting the correct one with a new Id.
• If cancelled, set the CarePlan.activity.detail.status and CarePlan.activity.detail.statusreason and report the Careplan again with the same Id as used earlier.
• If the timing is changing, it is most likely because a status has shown a new or an extra need of the citizen. Report this in a new CarePlan with a new start-date, rather than correcting the timing in the existing plan. This goes for PlannedInterventions that references the CarePlan as well.

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

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

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
identifier		0..0
instantiatesCanonical		0..0
instantiatesUri		0..0
basedOn		0..0
replaces		0..0
partOf		0..0
status		1..1	code	[DK] indsatsforløbsstatus
intent		1..1	code	[DK] indsatshensigt Required Pattern: plan
category		1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
title		0..0
description		0..0
subject		1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
encounter		0..0
period		1..1	Period	Time period plan covers
start		1..1	dateTime	[DK] indsatsforløbBevillingstid
end		0..1	dateTime	[DK] indsatforløbAfslutningstid
created		0..0
author		0..0
contributor		0..0
careTeam		0..0
addresses		0..0
supportingInfo		0..0
goal		0..0
activity		1..1	BackboneElement	Action to occur as part of plan
outcomeCodeableConcept		0..0
outcomeReference		0..0
progress		0..0
reference		0..0
detail		1..1	BackboneElement	In-line definition of activity
kind		0..0
instantiatesCanonical		0..0
instantiatesUri		0..0
code		0..0
reasonCode		0..0
reasonReference		0..0
goal		0..0
status		1..1	code	[DK] indsatsforløbsAktivitetsstatus
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
doNotPerform		0..0
scheduled[x]		0..0
location		0..0
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
product[x]		0..0
dailyAmount		0..0
quantity		0..0
description		0..0
note		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
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
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
extension		0..0
url		1..1	uri	"http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension"
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbsstatus 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] indsatshensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan. Required Pattern: plan
category	Σ	1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
subject	Σ	1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
period	Σ	1..1	Period	Time period plan covers
start	ΣC	1..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatforløbAfslutningstid
activity	C	1..1	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detail	C	1..1	BackboneElement	In-line definition of activity
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
status	?!	1..1	code	[DK] indsatsforløbsAktivitetsstatus Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
CarePlan.status	required	RequestStatus
CarePlan.intent	required	Pattern: plan
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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	CarePlan	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	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	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()
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
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
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension"
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbsstatus 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] indsatshensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan. Required Pattern: plan
category	Σ	1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
subject	Σ	1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
period	Σ	1..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	1..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatforløbAfslutningstid
activity	C	1..1	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
detail	C	1..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
status	?!	1..1	code	[DK] indsatsforløbsAktivitetsstatus Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
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	Pattern: plan
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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	CarePlan	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	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	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()
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

Differential View

This structure is derived from CarePlan

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
Slices for extension		0..*	Extension	Extension Slice: Unordered, Open by value:url
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
identifier		0..0
instantiatesCanonical		0..0
instantiatesUri		0..0
basedOn		0..0
replaces		0..0
partOf		0..0
status		1..1	code	[DK] indsatsforløbsstatus
intent		1..1	code	[DK] indsatshensigt Required Pattern: plan
category		1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
title		0..0
description		0..0
subject		1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
encounter		0..0
period		1..1	Period	Time period plan covers
start		1..1	dateTime	[DK] indsatsforløbBevillingstid
end		0..1	dateTime	[DK] indsatforløbAfslutningstid
created		0..0
author		0..0
contributor		0..0
careTeam		0..0
addresses		0..0
supportingInfo		0..0
goal		0..0
activity		1..1	BackboneElement	Action to occur as part of plan
outcomeCodeableConcept		0..0
outcomeReference		0..0
progress		0..0
reference		0..0
detail		1..1	BackboneElement	In-line definition of activity
kind		0..0
instantiatesCanonical		0..0
instantiatesUri		0..0
code		0..0
reasonCode		0..0
reasonReference		0..0
goal		0..0
status		1..1	code	[DK] indsatsforløbsAktivitetsstatus
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
doNotPerform		0..0
scheduled[x]		0..0
location		0..0
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
product[x]		0..0
dailyAmount		0..0
quantity		0..0
description		0..0
note		0..0
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
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
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
extension		0..0
url		1..1	uri	"http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension"
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbsstatus 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] indsatshensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan. Required Pattern: plan
category	Σ	1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
subject	Σ	1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
period	Σ	1..1	Period	Time period plan covers
start	ΣC	1..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatforløbAfslutningstid
activity	C	1..1	BackboneElement	Action to occur as part of plan
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
detail	C	1..1	BackboneElement	In-line definition of activity
modifierExtension	?!Σ	0..*	Extension	Extensions that cannot be ignored even if unrecognized
status	?!	1..1	code	[DK] indsatsforløbsAktivitetsstatus Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
CarePlan.status	required	RequestStatus
CarePlan.intent	required	Pattern: plan
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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	CarePlan	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	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	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()
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
CarePlan	C	0..*	CarePlan	Healthcare plan for patient or group klgateway-140-care-plan-1: status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited
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
basedOnServiceRequest		0..1	Reference(KLGateway140ServiceRequest)	[DK] indsatsforløbAnledning URL: http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension
id		0..1	string	Unique id for inter-element referencing
extension		0..0
url		1..1	uri	"http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension"
value[x]		1..1	Reference(KLGateway140ServiceRequest) {b}	Value of extension
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] indsatsforløbsstatus 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] indsatshensigt Binding: CarePlanIntent (required): Codes indicating the degree of authority/intentionality associated with a care plan. Required Pattern: plan
category	Σ	1..1	CodeableConcept	[DK] indsatsforløbKategori Binding: CarePlanCategories (required)
subject	Σ	1..1	Reference(KLGateway140Citizen) {b}	[DK] indsatssubjekt
period	Σ	1..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	1..1	dateTime	[DK] indsatsforløbBevillingstid
end	ΣC	0..1	dateTime	[DK] indsatforløbAfslutningstid
activity	C	1..1	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
detail	C	1..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
status	?!	1..1	code	[DK] indsatsforløbsAktivitetsstatus Binding: CarePlanActivityStatus (required): Codes that reflect the current state of a care plan activity within its overall life cycle.
statusReason		0..1	CodeableConcept	[DK] indsatsforløbForklaringAfStatus Binding: CancellationTypes (required)
performer		1..1	Reference(KLGateway140Organization) {b}	[DK] indsatsleverandør
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	Pattern: plan
CarePlan.category	required	CarePlanCategories140
CarePlan.activity.detail.status	required	CarePlanActivityStatus
CarePlan.activity.detail.statusReason	required	CancellationTypes

Constraints

Id	Grade	Path(s)	Details	Requirements
cpl-3	error	CarePlan.activity	Provide a reference or detail, not both : detail.empty() or reference.empty()
dom-2	error	CarePlan	If the resource is contained in another resource, it SHALL NOT contain nested Resources : contained.contained.empty()
dom-3	error	CarePlan	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	CarePlan	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	CarePlan	If a resource is contained in another resource, it SHALL NOT have a security label : contained.meta.security.empty()
dom-6	best practice	CarePlan	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()
klgateway-140-care-plan-1	error	CarePlan	status reason is mandatory if status is cancelled or stopped. Otherwise it is prohibited : activity.detail.all(statusReason.exists() = (status = 'cancelled' or status = 'stopped'))

This structure is derived from CarePlan

Summary

Mandatory: 6 elements
Prohibited: 35 elements

Structures

This structure refers to these other structures:

• KLGateway140ServiceRequest (http://fhir.kl.dk/rehab/StructureDefinition/klgateway-140-servicerequest)
• KLGateway140Citizen (http://fhir.kl.dk/rehab/StructureDefinition/klgateway-140-citizen)
• KLGateway140Organization (http://fhir.kl.dk/rehab/StructureDefinition/klgateway-140-organization)

Extensions

This structure refers to these extensions:

• http://fhir.kl.dk/rehab/StructureDefinition/BasedOnServiceRequestExtension