Implementation Guide for fælleskommunal informationsmodel
0.7.0 - CI Build
Implementation Guide for fælleskommunal informationsmodel
0.7.0 - CI Build
Implementation Guide for fælleskommunal informationsmodel - Local Development build (v0.7.0). See the Directory of published versions
| Official URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialCompletedIntervention | Version: 0.7.0 | |||
| Draft as of 2023-07-06 | Computable Name: KLCommonCareSocialCompletedIntervention | |||
Documentation for completed inteventions (activities related to one and only one encounter) in Danish municipalities
In a Danish municipality setting, CommonCareSocialCompletedIntervention is used to describe what activities has been delivered (e.g. a visit from a nurse to a citizen home where wound care is delivered). A CompletedIntervention always describes actual activities of one encounter. It should not be confused with PlannedIntervention, which describes the intention of activities, typically for several encounters. The CompletedIntervention may point to the request-resource that authorized the intervention. This can be either a PlannedIntervention, where the municipality visitation has authorized the intervention or a ServiceRequest, if the request directly has initiated the intervention e.g. acute nurse care issued by a general practitioner. It should be blank for activities delivered without pre-authorization e.g. when a home care practitioner comes to clean the house but finds the citizen on the floor after a fall and helps with this.
Procedure.complication.coding should be set if the planned intervention has been delivered with some complication. If the complication code is set, the basedOn-attribute should point to the relevant PlannedIntervention OR the code attribute should be populated with a FSIII or FFB intervention code. The complication should be described in Procedure.complication.text.
Procedure.performedPeriod.start og Procedure.performedPeriod.end are only important if the time spend on one out of more interventions delivered in one encounter needs monitoring. E.g. one home care visit on the 20th of June with cleaning from 8:30-8:50 and help with food preparation from 8:50-9:00.
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 |
|---|---|---|
| leveretIndsatsAktivitetstatus | Indikation af hvor i det kliniske forløb indsatsen er. | Procedure.status |
| leveretIndsatsAktivitetstatusTekst | Grund til at en indsats ikke er gennemført | Procedure.statusReason.text |
| leveretIndsatsAktivitetAfvigelseskode | En klasse der, hvis den er til stede, angiver på hvilken måde indsatsen ikke er leveret i overensstemmelse med den PlanlagteIndsats. | Procedure.complication.coding |
| leveretIndsatsAktivitetAfvigelsestekst | Beskrivelse af hvilken afvigelse der er ift. det planlagte | Procedure.complication.text |
| leveretIndsatsAktivitetNotat | Beskrivelse af hvilken indsats der konkret er leveret. | Procedure.note.text |
| leveretIndsatsAktivitetSubjekt | Den borger som indsatsen er leveret til. | Procedure.subject |
| leveretIndsatsAktivitetDokumenterendeLeverandør | Den leverandør, som er ansvarlig for dokumentationen af den leverede indsats. | Procedure.recorder |
| leveretIndsatsAktivitetKode | Klasse, der udtrykker hvad den leverede indsats omhandler. | Procedure.code.coding |
| leveretIndsatsAktivitetbevilling | Den autorisation som leveringen er baseret på via en reference til den planlagte og bevilgede indsats eller en henvisning fra læge. Er kun fraværende når leverandøren leverer noget andet end det planlagte på eget initiativ. | Procedure.basedOn |
| leveretIndsatsAktivitetKontakt | Den kontakt, hvor denne del af indsatsen leveres. | Procedure.encounter |
| leveretIndsatsAktivitetStart | Starttidspunkt for levering af indsatsen. | Procedure.performedPeriod.start |
| leveretIndsatsAktivitetSlut | Sluttidspunkt for levering af indsatsen. | Procedure.performedPeriod.end |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
  Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
  basedOn | 0..* | Reference(PlannedIntervention | ServiceRequest) | [DK] leveretIndsatsAktivitetbevilling | |
 status | 1..1 | code | [DK] leveretIndsatsAktivitetstatus | |
 statusReason | ||||
  text | 0..1 | string | [DK] leveretIndsatsAktivitetstatusTekst | |
| code | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) | |
| coding | 0..* | Coding | [DK] leveretIndsatsAktivitetKode | |
| subject | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt | |
| encounter | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt | |
 Slices for performed[x] | 0..1 | dateTime, Period, string, Age, Range | When the procedure was performed Slice: Unordered, Open by type:$this | |
  performed[x]:performedPeriod | 0..1 | Period | When the procedure was performed | |
  start | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart | |
 end | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut | |
| recorder | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør | |
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |
| coding | 0..* | Coding | [DK] leveretIndsatsAktivitetAfvigelseskode | |
| text | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst | |
 note | 0..1 | Annotation | Additional information about the procedure | |
| author[x] | 0..0 | |||
| text | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.code | required | KLInterventions |
| Procedure.complication | required | KLComplicationCodesSCT |
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
 implicitRules | ?!Σ | 0..1 | uri | A set of rules under which this content was created |
 modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
| basedOn | Σ | 0..* | Reference(PlannedIntervention | ServiceRequest) | [DK] leveretIndsatsAktivitetbevilling |
| status | ?!Σ | 1..1 | code | [DK] leveretIndsatsAktivitetstatus Binding: EventStatus (required): A code specifying the state of the procedure. |
 code | Σ | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) |
| coding | Σ | 0..* | Coding | [DK] leveretIndsatsAktivitetKode |
| subject | Σ | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt |
| encounter | Σ | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt |
| Slices for performed[x] | Σ | 0..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |
 performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| performedString | string | |||
| performedAge | Age | |||
| performedRange | Range | |||
| performed[x]:performedPeriod | Σ | 0..1 | Period | When the procedure was performed |
| start | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart |
| end | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut |
| recorder | Σ | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør |
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |
| coding | Σ | 0..* | Coding | [DK] leveretIndsatsAktivitetAfvigelseskode |
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst |
| note | 0..1 | Annotation | Additional information about the procedure | |
| text | Σ | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.status | required | EventStatus |
| Procedure.code | required | KLInterventions |
| Procedure.complication | required | KLComplicationCodesSCT |
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||
| 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 | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(PlannedIntervention | ServiceRequest) | [DK] leveretIndsatsAktivitetbevilling | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!Σ | 1..1 | code | [DK] leveretIndsatsAktivitetstatus Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| 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 | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetstatusTekst | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | Σ | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) | ||||
| 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] leveretIndsatsAktivitetKode | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt | ||||
| Slices for performed[x] | Σ | 0..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |||||
| performedDateTime | dateTime | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| performed[x]:performedPeriod | Σ | 0..1 | Period | When the procedure was performed | ||||
| 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 | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart | ||||
| end | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut | ||||
| recorder | Σ | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| 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 | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |||||
| 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] leveretIndsatsAktivitetAfvigelseskode | ||||
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst | ||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..1 | Annotation | Additional information about the procedure | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| time | Σ | 0..1 | dateTime | When the annotation was made | ||||
| text | Σ | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat | ||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| 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 | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | required | KLInterventions | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | example | ProcedureReasonCodes | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | required | KLComplicationCodesSCT | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from Procedure
Summary
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Procedure
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
| basedOn | 0..* | Reference(PlannedIntervention | ServiceRequest) | [DK] leveretIndsatsAktivitetbevilling | |
| status | 1..1 | code | [DK] leveretIndsatsAktivitetstatus | |
| statusReason | ||||
| text | 0..1 | string | [DK] leveretIndsatsAktivitetstatusTekst | |
| code | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) | |
| coding | 0..* | Coding | [DK] leveretIndsatsAktivitetKode | |
| subject | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt | |
| encounter | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt | |
| Slices for performed[x] | 0..1 | dateTime, Period, string, Age, Range | When the procedure was performed Slice: Unordered, Open by type:$this | |
| performed[x]:performedPeriod | 0..1 | Period | When the procedure was performed | |
| start | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart | |
| end | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut | |
| recorder | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør | |
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |
| coding | 0..* | Coding | [DK] leveretIndsatsAktivitetAfvigelseskode | |
| text | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst | |
| note | 0..1 | Annotation | Additional information about the procedure | |
| author[x] | 0..0 | |||
| text | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat | |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.code | required | KLInterventions |
| Procedure.complication | required | KLComplicationCodesSCT |
Key Elements View
| Name | Flags | Card. | Type | Description & Constraints |
|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |
| 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) | [DK] leveretIndsatsAktivitetbevilling |
| status | ?!Σ | 1..1 | code | [DK] leveretIndsatsAktivitetstatus Binding: EventStatus (required): A code specifying the state of the procedure. |
| code | Σ | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) |
| coding | Σ | 0..* | Coding | [DK] leveretIndsatsAktivitetKode |
| subject | Σ | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt |
| encounter | Σ | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt |
| Slices for performed[x] | Σ | 0..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |
| performedDateTime | dateTime | |||
| performedPeriod | Period | |||
| performedString | string | |||
| performedAge | Age | |||
| performedRange | Range | |||
| performed[x]:performedPeriod | Σ | 0..1 | Period | When the procedure was performed |
| start | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart |
| end | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut |
| recorder | Σ | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør |
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |
| coding | Σ | 0..* | Coding | [DK] leveretIndsatsAktivitetAfvigelseskode |
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst |
| note | 0..1 | Annotation | Additional information about the procedure | |
| text | Σ | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat |
| Documentation for this format | ||||
| Path | Conformance | ValueSet |
| Procedure.status | required | EventStatus |
| Procedure.code | required | KLInterventions |
| Procedure.complication | required | KLComplicationCodesSCT |
Snapshot View
| Name | Flags | Card. | Type | Description & Constraints | ||||
|---|---|---|---|---|---|---|---|---|
| Procedure | 0..* | Procedure | An action that is being or was performed on a patient | |||||
| 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 | External Identifiers for this procedure | ||||
| instantiatesCanonical | Σ | 0..* | canonical(PlanDefinition | ActivityDefinition | Measure | OperationDefinition | Questionnaire) | Instantiates FHIR protocol or definition | ||||
| instantiatesUri | Σ | 0..* | uri | Instantiates external protocol or definition | ||||
| basedOn | Σ | 0..* | Reference(PlannedIntervention | ServiceRequest) | [DK] leveretIndsatsAktivitetbevilling | ||||
| partOf | Σ | 0..* | Reference(Procedure | Observation | MedicationAdministration) | Part of referenced event | ||||
| status | ?!Σ | 1..1 | code | [DK] leveretIndsatsAktivitetstatus Binding: EventStatus (required): A code specifying the state of the procedure. | ||||
| statusReason | Σ | 0..1 | CodeableConcept | Reason for current status Binding: ProcedureNotPerformedReason(SNOMED-CT) (example): A code that identifies the reason a procedure was not performed. | ||||
| 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 | Code defined by a terminology system | ||||
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetstatusTekst | ||||
| category | Σ | 0..1 | CodeableConcept | Classification of the procedure Binding: ProcedureCategoryCodes(SNOMEDCT) (example): A code that classifies a procedure for searching, sorting and display purposes. | ||||
| code | Σ | 0..1 | CodeableConcept | Identification of the procedure Binding: KLIndsatser (required) | ||||
| 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] leveretIndsatsAktivitetKode | ||||
| text | Σ | 0..1 | string | Plain text representation of the concept | ||||
| subject | Σ | 1..1 | Reference(Citizen) | [DK] leveretIndsatsAktivitetSubjekt | ||||
| encounter | Σ | 0..1 | Reference(Encounter) | [DK] leveretIndsatsAktivitetKontakt | ||||
| Slices for performed[x] | Σ | 0..1 | When the procedure was performed Slice: Unordered, Open by type:$this | |||||
| performedDateTime | dateTime | |||||||
| performedPeriod | Period | |||||||
| performedString | string | |||||||
| performedAge | Age | |||||||
| performedRange | Range | |||||||
| performed[x]:performedPeriod | Σ | 0..1 | Period | When the procedure was performed | ||||
| 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 | 0..1 | dateTime | [DK] leveretIndsatsAktivitetStart | ||||
| end | ΣC | 0..1 | dateTime | [DK] leveretIndsatsAktivitetSlut | ||||
| recorder | Σ | 0..1 | Reference(Practioner) | [DK] leveretIndsatsAktivitetDokumenterendeLeverandør | ||||
| asserter | Σ | 0..1 | Reference(Patient | RelatedPerson | Practitioner | PractitionerRole) | Person who asserts this procedure | ||||
| performer | Σ | 0..* | BackboneElement | The people who performed the procedure | ||||
| 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 | ||||
| function | Σ | 0..1 | CodeableConcept | Type of performance Binding: ProcedurePerformerRoleCodes (example): A code that identifies the role of a performer of the procedure. | ||||
| actor | Σ | 1..1 | Reference(Practitioner | PractitionerRole | Organization | Patient | RelatedPerson | Device) | The reference to the practitioner | ||||
| onBehalfOf | 0..1 | Reference(Organization) | Organization the device or practitioner was acting for | |||||
| location | Σ | 0..1 | Reference(Location) | Where the procedure happened | ||||
| reasonCode | Σ | 0..* | CodeableConcept | Coded reason procedure performed Binding: ProcedureReasonCodes (example): A code that identifies the reason a procedure is required. | ||||
| reasonReference | Σ | 0..* | Reference(Condition | Observation | Procedure | DiagnosticReport | DocumentReference) | The justification that the procedure was performed | ||||
| bodySite | Σ | 0..* | CodeableConcept | Target body sites Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
| outcome | Σ | 0..1 | CodeableConcept | The result of procedure Binding: ProcedureOutcomeCodes(SNOMEDCT) (example): An outcome of a procedure - whether it was resolved or otherwise. | ||||
| report | 0..* | Reference(DiagnosticReport | DocumentReference | Composition) | Any report resulting from the procedure | |||||
| complication | 0..1 | CodeableConcept | Complication following the procedure Binding: KLKomplikationskoderSCT (required) | |||||
| 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] leveretIndsatsAktivitetAfvigelseskode | ||||
| text | Σ | 0..1 | string | [DK] leveretIndsatsAktivitetAfvigelsestekst | ||||
| complicationDetail | 0..* | Reference(Condition) | A condition that is a result of the procedure | |||||
| followUp | 0..* | CodeableConcept | Instructions for follow up Binding: ProcedureFollowUpCodes(SNOMEDCT) (example): Specific follow up required for a procedure e.g. removal of sutures. | |||||
| note | 0..1 | Annotation | Additional information about the procedure | |||||
| id | 0..1 | string | Unique id for inter-element referencing | |||||
| extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
| time | Σ | 0..1 | dateTime | When the annotation was made | ||||
| text | Σ | 1..1 | markdown | [DK] leveretIndsatsAktivitetNotat | ||||
| focalDevice | 0..* | BackboneElement | Manipulated, implanted, or removed device | |||||
| 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 | ||||
| action | 0..1 | CodeableConcept | Kind of change to device Binding: ProcedureDeviceActionCodes (preferred): A kind of change that happened to the device during the procedure. | |||||
| manipulated | 1..1 | Reference(Device) | Device that was changed | |||||
| usedReference | 0..* | Reference(Device | Medication | Substance) | Items used during procedure | |||||
| usedCode | 0..* | CodeableConcept | Coded items used during the procedure Binding: FHIRDeviceTypes (example): Codes describing items used during a procedure. | |||||
| Documentation for this format | ||||||||
| Path | Conformance | ValueSet | ||||
| Procedure.language | preferred | CommonLanguages
| ||||
| Procedure.status | required | EventStatus | ||||
| Procedure.statusReason | example | ProcedureNotPerformedReason(SNOMED-CT) | ||||
| Procedure.category | example | ProcedureCategoryCodes(SNOMEDCT) | ||||
| Procedure.code | required | KLInterventions | ||||
| Procedure.performer.function | example | ProcedurePerformerRoleCodes | ||||
| Procedure.reasonCode | example | ProcedureReasonCodes | ||||
| Procedure.bodySite | example | SNOMEDCTBodyStructures | ||||
| Procedure.outcome | example | ProcedureOutcomeCodes(SNOMEDCT) | ||||
| Procedure.complication | required | KLComplicationCodesSCT | ||||
| Procedure.followUp | example | ProcedureFollowUpCodes(SNOMEDCT) | ||||
| Procedure.focalDevice.action | preferred | ProcedureDeviceActionCodes | ||||
| Procedure.usedCode | example | FHIRDeviceTypes |
This structure is derived from Procedure
Summary
Prohibited: 1 element
Structures
This structure refers to these other structures:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron