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/KLCommonCareSocialCondition | Version: 0.7.0 | |||
Draft as of 2023-07-06 | Computable Name: KLCommonCareSocialCondition |
Detailed information about conditions in Danish municiplities health, social and elderly care.
The KLCommonCareSocialCondition may be instatiated whenever a condition is found and registered for citizens in Danish municipalities. In social care, conditions are also referred to as subthemes (undertemaer).
Conditions are always defined by Condition.code, which may originate from FSIII or FFB. In addition, a SNOMED CT code may be added either to improve understanding for those outside the Danish municipalities, or to express more detailed content.
Condition.severity.coding has as valid values the functioning ability levels (FFB funktionsevneniveau) or funtional levels (FSIII funktionsniveau). Make sure that FFB subthemes use FFB functioning ability levels and FSIII conditions use FSIII functional levels - the codes have somewhat the same wording, but they do not have the same meaning.
Condition.recordedDate is the date where the condition was first recorded, NOT the date where the problem first known to be present.
Condition.clinicalStatus should be populated with the value “active” if the citizen has the condition, and inactive if the citizen no longer have the condition. Condition.verificationStatus should be set to “unconfirmed”, if a note is associated with a condition code, which is not already active and confirmed (this is specific to FFB). In most other use cases, Condition.verificationStatus should be “confirmed”. clinicalStatus is mandatory, and it is a good idea to always provide the verificationStatus. If not populated, the condition is assumed to be “confirmed”.
Conditions are related to a professional context (through its code). These are the different contexts in which codelists of conditions are formulated:
Condition.category is, in this implementation, used as a way to determine whether the condition is in focus in a professional context. In focus means that this condition is solely or partially the reason why interventions are performed in the professional context. If a condition is “in focus” Condition.category is populated with the value “problem-list-item”. An empty Condition.category means that the focus have not been considered (if it is the first version of a condition). If the latter is the case, it might be difficult to determine whether a condition have been ended.
Ending a condition have two meanings. The first is that the citizen no longer has the condition e.g. a pressure ulcer has healed. In this case, Condition.clinicalStatus=inactive and Condition.abatementTime is the date where the condition was no longer a problem. The second meaning of “ended” is that the condition falls out of focus in a professional context e.g. if the citizen moves, or another professional group takes over the care for the citizen. In this case, the Condition.category looses its “problem-list-item” flag. The idea is to state that from a citizen viewpoint the condition has not changed, but in this professional context it is no longer in focus.
Condition.code.text holds a short description or evaluation of the condition including how serious it is. The attribute is mandatory for the home nursing context. The attribute should only be changed, if the condition significatly changes e.g. a pressure ulcer that is significantly worse or better. All other text descriptions and notes should be placed in Condition.note.text. For most use cases, it is important that notes explicitely state the author in Condition.note.author. Special care should be taken if you want to explicitely state the source of the information, as it is explicitely done in FFB for ‘activity and participation conditions’. It is recommended that ‘information from the citizen’, ‘information from others’ and ‘employee evaluation’(sagsbehandlers bemærkning) are documented using three separate Condition.note.text and with the correct associated code in Condition.note:extension.matterOfInterestInformer. The employee evaluation should be documented in short form in Condition.code.text.
Condition.extension:dueTo is the reason for the condition, which is an optional attribute in FSIII. It references either KLCommonCareSocialCondition or KLCommonCareSocialFocusCondition.
Condition follow-up is documented using Condition.extension:followUpEncounter, which points to a future encounter, with Encounter.type= “opfølgning”.
Condition.evidence.detail may hold a reference to both KLCommonCareSocialMatterOfInterest and KLCommonCareSocialEvaluation. Associated KLCommonCareSocialEvaluations are previous follow-up results. Associated KLCommonCareSocialMatterOfInterest’s are information about the citizen recorded under the headings defined by FFB Themes, Areas (FSIII områder), which are related to this specific condition. E.g. if the condition is “J3.4 - Færden i forskellige omgivelser” then there might be associated information recorded as a KLCommonCareSocialMatterOfInterest within the code “J3 - Mobilitet”.
Conditions may have several different versions. Those that are important from a municipality viewpoint may be followed using the extension:EventHistory.
Condition.extension:conditionLastAssertedDate holds information about the last date a condition was confirmed valid in its current state. Eg. with its current clinical- and verification status, and severity. In municipalities, this is often the date of the last performed follow-up, given that the follow-up has included an active evaluation of this particular condition. Note that the condition need not have changed (e.g. severity or status) to have a new conditionLastAssertedDate
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 |
---|---|---|
tilstandskode | Udtrykker hvilken klasse tilstanden tilhører. | Condition.code.coding |
tilstandssværhedsgrad | Udtrykker hvilken klasse tilstandens sværhedsgrad har. | Condition.severity.coding |
tilstandsstatus | Klasse der udtrykker en status for om tilstanden er til stede eller ej. | Condition.clinicalStatus og Condition.verificationStatus |
tilstandsvurdering | Beskrivelse af en persontilstand | Condition.code.text |
tilstandFagligtNotat | Beskrivelse af løbende status, der ikke ændrer på vurdering, og sværhedsgrad. | Condition.note.text |
tilstandsInformant | Klasse der udtrykker hvem oplysninger vedr. tilstanden kommer fra. | Condition.note.extension:matterOfInterestInformer |
tilstandsoprettelsestid | Tidsangivelse for hvornår tilstanden først blev oprettet i journalen | Condition.recordedDate |
tilstandsafslutningstid | Tidsangivelse for hvornår tilstanden er afsluttet. Med afsluttet menes at tilstanden ikke mere er et problem for borger. | Condition.abatementDateTime |
tilstandsplanlagtOpfølgning | Kontakt, hvor det planlægges at følge op på tilstanden | Condition.extension:followUpEncounter |
tilstandsårsag | Årsag til en persontilstand | Condition.extension:dueTo |
tilstandssubjekt | Den borger som har tilstanden | Condition.subject |
tilstandsansvarlig | Den fagperson, der bedømmer borgerns tilstand | Condition.asserter |
tilstandsændringshistorie | Tidligere versioner af tilstanden, hvor der er sket klinisk relevante ændringer | Condition.extension:eventHistory |
tilstandsevidens | Oplysning fra en udredning eller afklaring, der ligger til grund for denne tilstand, eller opfølgningsresultater, der er opfølgning på denne tilstand til forskellige tider. | Condition.evidence.detail |
tilstandsfokus | Klasse der udtrykker, om en faggruppe har tilstanden i fokus for sine indsatser | Condition.category.coding |
tilstandSidstVurderetTid | Tidsangivelse for hvornår tilstanden sidst er vurderet valid i sin nuværende form (fx sværhedsgrad og status). | Condition.extension:conditionLastAssertedDate |
Usage:
Description of Profiles, Differentials, Snapshots and how the different presentations work.
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist |
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. |
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter |
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate |
clinicalStatus | 1..1 | CodeableConcept | [DK] tilstandsstatus | |
verificationStatus | 0..1 | CodeableConcept | [DK] tilstandsstatus | |
category | ||||
coding | 0..* | Coding | [DK] tilstandsfokus | |
severity | ?! | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (required) |
coding | 0..* | Coding | [DK] tilstandssværhedsgrad | |
code | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis | |
Slices for coding | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system | |
coding:FSIIIConditionCode | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII | |
coding:FFBConditionCode | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB | |
coding:SCTConditionCode | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | |
text | 0..1 | string | [DK] tilstandsvurdering | |
subject | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt | |
abatement[x] | 0..1 | dateTime | [DK] tilstandsafslutningstid | |
recordedDate | 0..1 | dateTime | [DK] tilstandsoprettelsestid | |
asserter | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig | |
evidence | ||||
detail | 0..* | Reference(MatterOfInterest | FollowUp) | [DK] tilstandsevidens (herunder tilstandOplysning og tilstandOpfølgningsresultat) | |
note | ||||
matterOfInterestInformer | 0..1 | CodeableConcept | [DK] tilstandsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required) | |
author[x] | 0..1 | Reference(Practioner) | Individual responsible for the annotation | |
text | 1..1 | markdown | [DK] tilstandFagligtNotat | |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.severity | required | KLSeverities |
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII |
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB |
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes |
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
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 | |
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist |
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | |
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter |
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!ΣC | 1..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (required) | |
coding | Σ | 0..* | Coding | [DK] tilstandssværhedsgrad |
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. |
Slices for coding | Σ | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system |
coding:FSIIIConditionCode | Σ | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII |
coding:FFBConditionCode | Σ | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB |
coding:SCTConditionCode | Σ | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
text | Σ | 0..1 | string | [DK] tilstandsvurdering |
subject | Σ | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt |
abatement[x] | C | 0..1 | dateTime | [DK] tilstandsafslutningstid |
recordedDate | Σ | 0..1 | dateTime | [DK] tilstandsoprettelsestid |
asserter | Σ | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.severity | required | KLSeverities |
Condition.code | example | Condition/Problem/DiagnosisCodes |
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII |
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB |
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes |
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses | ||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist | ||||
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | |||||
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |||||
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter | ||||
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!ΣC | 1..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |||||
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] tilstandsfokus | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (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] tilstandssværhedsgrad | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system | ||||
coding:FSIIIConditionCode | Σ | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:FFBConditionCode | Σ | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:SCTConditionCode | Σ | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | [DK] tilstandsvurdering | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | Σ | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
onset[x] | Σ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | C | 0..1 | dateTime | [DK] tilstandsafslutningstid | ||||
recordedDate | Σ | 0..1 | dateTime | [DK] tilstandsoprettelsestid | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
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 | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
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 | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(MatterOfInterest | FollowUp) | [DK] tilstandsevidens (herunder tilstandOplysning og tilstandOpfølgningsresultat) | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
matterOfInterestInformer | 0..1 | CodeableConcept | [DK] tilstandsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required) | |||||
author[x] | Σ | 0..1 | Reference(Practioner) | Individual responsible for the annotation | ||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | Σ | 1..1 | markdown | [DK] tilstandFagligtNotat | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | ConditionCategoryCodes | ||||
Condition.severity | required | KLSeverities | ||||
Condition.code | example | Condition/Problem/DiagnosisCodes | ||||
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII | ||||
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB | ||||
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
This structure is derived from Condition
Summary
Mandatory: 2 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Differential View
This structure is derived from Condition
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | 0..* | Condition | Detailed information about conditions, problems or diagnoses | |
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist |
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. |
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter |
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate |
clinicalStatus | 1..1 | CodeableConcept | [DK] tilstandsstatus | |
verificationStatus | 0..1 | CodeableConcept | [DK] tilstandsstatus | |
category | ||||
coding | 0..* | Coding | [DK] tilstandsfokus | |
severity | ?! | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (required) |
coding | 0..* | Coding | [DK] tilstandssværhedsgrad | |
code | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis | |
Slices for coding | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system | |
coding:FSIIIConditionCode | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII | |
coding:FFBConditionCode | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB | |
coding:SCTConditionCode | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (required) | |
system | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | |
text | 0..1 | string | [DK] tilstandsvurdering | |
subject | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt | |
abatement[x] | 0..1 | dateTime | [DK] tilstandsafslutningstid | |
recordedDate | 0..1 | dateTime | [DK] tilstandsoprettelsestid | |
asserter | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig | |
evidence | ||||
detail | 0..* | Reference(MatterOfInterest | FollowUp) | [DK] tilstandsevidens (herunder tilstandOplysning og tilstandOpfølgningsresultat) | |
note | ||||
matterOfInterestInformer | 0..1 | CodeableConcept | [DK] tilstandsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required) | |
author[x] | 0..1 | Reference(Practioner) | Individual responsible for the annotation | |
text | 1..1 | markdown | [DK] tilstandFagligtNotat | |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.severity | required | KLSeverities |
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII |
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB |
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes |
Key Elements View
Name | Flags | Card. | Type | Description & Constraints |
---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses |
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 | |
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist |
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. |
extension | 0..0 | |||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | |
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter |
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate |
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored |
clinicalStatus | ?!ΣC | 1..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. |
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. |
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (required) | |
coding | Σ | 0..* | Coding | [DK] tilstandssværhedsgrad |
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. |
Slices for coding | Σ | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system |
coding:FSIIIConditionCode | Σ | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII |
coding:FFBConditionCode | Σ | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB |
coding:SCTConditionCode | Σ | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (required) |
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct |
text | Σ | 0..1 | string | [DK] tilstandsvurdering |
subject | Σ | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt |
abatement[x] | C | 0..1 | dateTime | [DK] tilstandsafslutningstid |
recordedDate | Σ | 0..1 | dateTime | [DK] tilstandsoprettelsestid |
asserter | Σ | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig |
Documentation for this format |
Path | Conformance | ValueSet |
Condition.clinicalStatus | required | ConditionClinicalStatusCodes |
Condition.verificationStatus | required | ConditionVerificationStatus |
Condition.severity | required | KLSeverities |
Condition.code | example | Condition/Problem/DiagnosisCodes |
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII |
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB |
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes |
Snapshot View
Name | Flags | Card. | Type | Description & Constraints | ||||
---|---|---|---|---|---|---|---|---|
Condition | C | 0..* | Condition | Detailed information about conditions, problems or diagnoses | ||||
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 | |||||
Slices for extension | 0..* | Extension | Extension Slice: Unordered, Open by value:url | |||||
eventHistory | Σ | 0..* | Reference(Provenance) | [DK] tilstandsændringshistorie URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ExtEventHist | ||||
dueTo | Σ | 0..1 | CodeableConcept, Reference(Condition | Procedure | MedicationAdministration | Immunization | MedicationStatement) | [DK] tilstandsårsag URL: http://hl7.org/fhir/StructureDefinition/condition-dueTo Binding: ConditionCauseCodes (example): Codes that describe causes of patient conditions; e.g. Surgical mishap, escalation of a previous condition, etc. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..0 | |||||||
url | 1..1 | uri | "http://hl7.org/fhir/StructureDefinition/condition-dueTo" | |||||
value[x] | 1..1 | Reference(Condition | FocusCondition) | Value of extension | |||||
followUpEncounter | Σ | 0..1 | Reference(Encounter) | [DK] tilstandsplanlagtOpfølgning URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/FollowUpEncounter | ||||
conditionLastAssertedDate | Σ | 0..1 | dateTime | [DK] tilstandSidstVurderetTid URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/ConditionLastAssertedDate | ||||
modifierExtension | ?! | 0..* | Extension | Extensions that cannot be ignored | ||||
identifier | Σ | 0..* | Identifier | External Ids for this condition | ||||
clinicalStatus | ?!ΣC | 1..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionClinicalStatusCodes (required): The clinical status of the condition or diagnosis. | ||||
verificationStatus | ?!ΣC | 0..1 | CodeableConcept | [DK] tilstandsstatus Binding: ConditionVerificationStatus (required): The verification status to support or decline the clinical status of the condition or diagnosis. | ||||
category | 0..* | CodeableConcept | problem-list-item | encounter-diagnosis Binding: ConditionCategoryCodes (extensible): A category assigned to the condition. | |||||
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] tilstandsfokus | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
severity | 0..1 | CodeableConcept | Subjective severity of condition Binding: KLSværhedgrader (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] tilstandssværhedsgrad | ||||
text | Σ | 0..1 | string | Plain text representation of the concept | ||||
code | Σ | 1..1 | CodeableConcept | Identification of the condition, problem or diagnosis Binding: Condition/Problem/DiagnosisCodes (example): Identification of the condition or diagnosis. | ||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
Slices for coding | Σ | 0..* | Coding | [DK] tilstandskode Slice: Unordered, Open by value:system | ||||
coding:FSIIIConditionCode | Σ | 0..1 | Coding | [DK] FSIII tilstandskode Binding: KLTilstandKoderFSIII (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FSIII | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:FFBConditionCode | Σ | 0..1 | Coding | [DK] FFB undertemakode Binding: KLTilstandKoderFFB (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://kl.dk/fhir/common/caresocial/CodeSystem/FFB | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
coding:SCTConditionCode | Σ | 0..1 | Coding | [DK] SNOMED CT tilstandskode Binding: Condition/Problem/DiagnosisCodes (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 | |||||
system | Σ | 1..1 | uri | Identity of the terminology system Required Pattern: http://snomed.info/sct | ||||
version | Σ | 0..1 | string | Version of the system - if relevant | ||||
code | Σ | 0..1 | code | Symbol in syntax defined by the system | ||||
display | Σ | 0..1 | string | Representation defined by the system | ||||
userSelected | Σ | 0..1 | boolean | If this coding was chosen directly by the user | ||||
text | Σ | 0..1 | string | [DK] tilstandsvurdering | ||||
bodySite | Σ | 0..* | CodeableConcept | Anatomical location, if relevant Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality. | ||||
subject | Σ | 1..1 | Reference(Citizen) | [DK] tilstandssubjekt | ||||
encounter | Σ | 0..1 | Reference(Encounter) | Encounter created as part of | ||||
onset[x] | Σ | 0..1 | Estimated or actual date, date-time, or age | |||||
onsetDateTime | dateTime | |||||||
onsetAge | Age | |||||||
onsetPeriod | Period | |||||||
onsetRange | Range | |||||||
onsetString | string | |||||||
abatement[x] | C | 0..1 | dateTime | [DK] tilstandsafslutningstid | ||||
recordedDate | Σ | 0..1 | dateTime | [DK] tilstandsoprettelsestid | ||||
recorder | Σ | 0..1 | Reference(Practitioner | PractitionerRole | Patient | RelatedPerson) | Who recorded the condition | ||||
asserter | Σ | 0..1 | Reference(Practioner) | [DK] tilstandsansvarlig | ||||
stage | C | 0..* | BackboneElement | Stage/grade, usually assessed formally | ||||
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 | ||||
summary | C | 0..1 | CodeableConcept | Simple summary (disease specific) Binding: ConditionStage (example): Codes describing condition stages (e.g. Cancer stages). | ||||
assessment | C | 0..* | Reference(ClinicalImpression | DiagnosticReport | Observation) | Formal record of assessment | ||||
type | 0..1 | CodeableConcept | Kind of staging Binding: ConditionStageType (example): Codes describing the kind of condition staging (e.g. clinical or pathological). | |||||
evidence | C | 0..* | BackboneElement | Supporting evidence | ||||
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 | ΣC | 0..* | CodeableConcept | Manifestation/symptom Binding: ManifestationAndSymptomCodes (example): Codes that describe the manifestation or symptoms of a condition. | ||||
detail | ΣC | 0..* | Reference(MatterOfInterest | FollowUp) | [DK] tilstandsevidens (herunder tilstandOplysning og tilstandOpfølgningsresultat) | ||||
note | 0..* | Annotation | Additional information about the Condition | |||||
id | 0..1 | string | Unique id for inter-element referencing | |||||
Slices for extension | 0..* | Extension | Additional content defined by implementations Slice: Unordered, Open by value:url | |||||
matterOfInterestInformer | 0..1 | CodeableConcept | [DK] tilstandsInformant URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/MatterOfInterestInformer Binding: KLKildeTilOplysningFFB (required) | |||||
author[x] | Σ | 0..1 | Reference(Practioner) | Individual responsible for the annotation | ||||
time | Σ | 0..1 | dateTime | When the annotation was made | ||||
text | Σ | 1..1 | markdown | [DK] tilstandFagligtNotat | ||||
Documentation for this format |
Path | Conformance | ValueSet | ||||
Condition.language | preferred | CommonLanguages
| ||||
Condition.clinicalStatus | required | ConditionClinicalStatusCodes | ||||
Condition.verificationStatus | required | ConditionVerificationStatus | ||||
Condition.category | extensible | ConditionCategoryCodes | ||||
Condition.severity | required | KLSeverities | ||||
Condition.code | example | Condition/Problem/DiagnosisCodes | ||||
Condition.code.coding:FSIIIConditionCode | required | KLConditionCodesFSIII | ||||
Condition.code.coding:FFBConditionCode | required | KLConditionCodesFFB | ||||
Condition.code.coding:SCTConditionCode | required | Condition/Problem/DiagnosisCodes | ||||
Condition.bodySite | example | SNOMEDCTBodyStructures | ||||
Condition.stage.summary | example | ConditionStage | ||||
Condition.stage.type | example | ConditionStageType | ||||
Condition.evidence.code | example | ManifestationAndSymptomCodes |
This structure is derived from Condition
Summary
Mandatory: 2 elements (3 nested mandatory elements)
Structures
This structure refers to these other structures:
Extensions
This structure refers to these extensions:
Slices
This structure defines the following Slices:
Other representations of profile: CSV, Excel, Schematron