Implementation Guide for fælleskommunal informationsmodel
0.7.0 - CI Build Denmark flag

Implementation Guide for fælleskommunal informationsmodel - Local Development build (v0.7.0). See the Directory of published versions

Resource Profile: FollowUp

Official URL: http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialFollowUp Version: 0.7.0
Draft as of 2023-07-06 Computable Name: KLCommonCareSocialFollowUp

Follow-up results used in Danish municipalities

Scope and usage

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

The profile has a text-based follow-up results in Observation.valueCodeableConcept.text, and a structured Follow-up result in Observation.valueCodeableConcept.coding

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

Note that this ressource may reference an Encounter. Use this opportunity only if the follow-up takes place in an actual meeting between a practitioner and citizen.

The focus of the follow-up can be documented in Observation.focus, so that it becomes explicite which conditions and interventions this follow-up result pertains to.

Conversions between Danish information model and FHIR-profile

Nedenstående tabel oversætter mellem de attributter der er defineret i den fælleskommunale informationsmodel (FKI), definerer kort den enkelte attribut på dansk og specificerer, hvilke af FHIR-profilens atributter, der skal bruges til specifikation af indholdet.

FKI-attribut Definition FHIR
opfølgningsresultatKode Klasse, der udtrykker at der evalueres på den indsats der er igangsat. Observation.code.coding
opfølgningsresultat Tekst der udtrykker hvad resultatet af opfølgningen er. Observation.valueCodeableConcept.text
opfølgningsresultatStruktureret Struktureret resultat af en opfølgningen Observation.valueCodeableConcept.coding
opfølgningsresultatSubjekt Den borger, der er genstand for opfølgningen Observation.subject
opfølgningsresultatKontakt Den kontakt hvor opfølgningen er foretaget Observation.encounter
opfølgningsresultatAnsvarlig Den fagperson der har ansvaret for opfølgningen Observation.performer
opfølgningsresultatTid Det tidspunkt, hvor opfølgningen er foretaget Observation.effectiveDateTime
opfølgningsresultatStatus Kode der udtrykker, hvor i sin proces, opfølgningen er Observation.status
opfølgningsresultatFokus Den eller de tilstande og indsatser der er fokus for opfølgningen. Observation.focus

Usage:

Formal Views of Profile Content

Description of Profiles, Differentials, Snapshots and how the different presentations work.

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... status 1..1code[DK] opfølgningsresultatStatus
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
.... coding 0..*Coding[DK] opfølgningsresultatkode
... subject 0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... encounter 0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] 1..1dateTime[DK] opfølgningsresultatTid
... performer 0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] 0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... coding 0..*Coding[DK] struktureretOpfølgningsresultat
.... text 0..1string[DK] opfølgningsresultat

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value[x]requiredKLFollowUpCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1code[DK] opfølgningsresultatStatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
.... coding Σ0..*Coding[DK] opfølgningsresultatkode
... subject Σ0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... focus Σ0..*Reference(PlannedIntervention | Condition | CarePlan)[DK] opfølgningsresultatFokus
... encounter Σ0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] Σ1..1dateTime[DK] opfølgningsresultatTid
... performer Σ0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... coding Σ0..*Coding[DK] struktureretOpfølgningsresultat
.... text Σ0..1string[DK] opfølgningsresultat

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.statusrequiredObservationStatus
Observation.codeexamplePattern: SNOMED CT code 712744002
Observation.value[x]requiredKLFollowUpCodes
NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1code[DK] opfølgningsresultatStatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] opfølgningsresultatkode
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... focus Σ0..*Reference(PlannedIntervention | Condition | CarePlan)[DK] opfølgningsresultatFokus
... encounter Σ0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] Σ1..1dateTime[DK] opfølgningsresultatTid
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] struktureretOpfølgningsresultat
.... text Σ0..1string[DK] opfølgningsresultat
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.codeexamplePattern: SNOMED CT code 712744002
Observation.value[x]requiredKLFollowUpCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

Differential View

This structure is derived from Observation

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation 0..*ObservationMeasurements and simple assertions
... status 1..1code[DK] opfølgningsresultatStatus
... code 1..1CodeableConceptType of observation (code / type)
Required Pattern: At least the following
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
.... coding 0..*Coding[DK] opfølgningsresultatkode
... subject 0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... encounter 0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] 1..1dateTime[DK] opfølgningsresultatTid
... performer 0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] 0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... coding 0..*Coding[DK] struktureretOpfølgningsresultat
.... text 0..1string[DK] opfølgningsresultat

doco Documentation for this format

Terminology Bindings (Differential)

PathConformanceValueSet
Observation.value[x]requiredKLFollowUpCodes

Key Elements View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... status ?!Σ1..1code[DK] opfølgningsresultatStatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
.... coding Σ0..*Coding[DK] opfølgningsresultatkode
... subject Σ0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... focus Σ0..*Reference(PlannedIntervention | Condition | CarePlan)[DK] opfølgningsresultatFokus
... encounter Σ0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] Σ1..1dateTime[DK] opfølgningsresultatTid
... performer Σ0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... coding Σ0..*Coding[DK] struktureretOpfølgningsresultat
.... text Σ0..1string[DK] opfølgningsresultat

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.statusrequiredObservationStatus
Observation.codeexamplePattern: SNOMED CT code 712744002
Observation.value[x]requiredKLFollowUpCodes

Snapshot View

NameFlagsCard.TypeDescription & Constraintsdoco
.. Observation C0..*ObservationMeasurements and simple assertions
... id Σ0..1idLogical id of this artifact
... meta Σ0..1MetaMetadata about the resource
... implicitRules ?!Σ0..1uriA set of rules under which this content was created
... language 0..1codeLanguage of the resource content
Binding: CommonLanguages (preferred): A human language.

Additional BindingsPurpose
AllLanguagesMax Binding
... text 0..1NarrativeText summary of the resource, for human interpretation
... contained 0..*ResourceContained, inline Resources
... extension 0..*ExtensionAdditional content defined by implementations
... modifierExtension ?!0..*ExtensionExtensions that cannot be ignored
... identifier Σ0..*IdentifierBusiness Identifier for observation
... basedOn Σ0..*Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)Fulfills plan, proposal or order
... partOf Σ0..*Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)Part of referenced event
... status ?!Σ1..1code[DK] opfølgningsresultatStatus
Binding: ObservationStatus (required): Codes providing the status of an observation.

... category 0..*CodeableConceptClassification of type of observation
Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.


... code Σ1..1CodeableConceptType of observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.


Required Pattern: At least the following
.... id0..1stringUnique id for inter-element referencing
.... extension0..*ExtensionAdditional content defined by implementations
.... coding1..*CodingCode defined by a terminology system
Fixed Value: (complex)
..... id0..1stringUnique id for inter-element referencing
..... extension0..*ExtensionAdditional content defined by implementations
..... system1..1uriIdentity of the terminology system
Fixed Value: http://snomed.info/sct
..... version0..1stringVersion of the system - if relevant
..... code1..1codeSymbol in syntax defined by the system
Fixed Value: 712744002
..... display0..1stringRepresentation defined by the system
..... userSelected0..1booleanIf this coding was chosen directly by the user
.... text0..1stringPlain text representation of the concept
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] opfølgningsresultatkode
.... text Σ0..1stringPlain text representation of the concept
... subject Σ0..1Reference(Citizen)[DK] opfølgningsresultatSubjekt
... focus Σ0..*Reference(PlannedIntervention | Condition | CarePlan)[DK] opfølgningsresultatFokus
... encounter Σ0..1Reference(Encounter)[DK] opfølgningsresultatKontakt
... effective[x] Σ1..1dateTime[DK] opfølgningsresultatTid
... issued Σ0..1instantDate/Time this version was made available
... performer Σ0..*Reference(Practioner)[DK] opfølgningsresultatAnsvarlig
... value[x] ΣC0..1CodeableConceptActual result
Binding: KLOpfølgningKodes (required)
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
Slice: Unordered, Open by value:url
.... coding Σ0..*Coding[DK] struktureretOpfølgningsresultat
.... text Σ0..1string[DK] opfølgningsresultat
... dataAbsentReason C0..1CodeableConceptWhy the result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


... note 0..*AnnotationComments about the observation
... bodySite 0..1CodeableConceptObserved body part
Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.

... method 0..1CodeableConceptHow it was done
Binding: ObservationMethods (example): Methods for simple observations.

... specimen 0..1Reference(Specimen)Specimen used for this observation
... device 0..1Reference(Device | DeviceMetric)(Measurement) Device
... referenceRange C0..*BackboneElementProvides guide for interpretation
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... low C0..1SimpleQuantityLow Range, if relevant
.... high C0..1SimpleQuantityHigh Range, if relevant
.... type 0..1CodeableConceptReference range qualifier
Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.

.... appliesTo 0..*CodeableConceptReference range population
Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.


.... age 0..1RangeApplicable age range, if relevant
.... text 0..1stringText based reference range in an observation
... hasMember Σ0..*Reference(Observation | QuestionnaireResponse | MolecularSequence)Related resource that belongs to the Observation group
... derivedFrom Σ0..*Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)Related measurements the observation is made from
... component Σ0..*BackboneElementComponent results
.... id 0..1stringUnique id for inter-element referencing
.... extension 0..*ExtensionAdditional content defined by implementations
.... modifierExtension ?!Σ0..*ExtensionExtensions that cannot be ignored even if unrecognized
.... code Σ1..1CodeableConceptType of component observation (code / type)
Binding: LOINCCodes (example): Codes identifying names of simple observations.

.... value[x] Σ0..1Actual component result
..... valueQuantityQuantity
..... valueCodeableConceptCodeableConcept
..... valueStringstring
..... valueBooleanboolean
..... valueIntegerinteger
..... valueRangeRange
..... valueRatioRatio
..... valueSampledDataSampledData
..... valueTimetime
..... valueDateTimedateTime
..... valuePeriodPeriod
.... dataAbsentReason C0..1CodeableConceptWhy the component result is missing
Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.

.... interpretation 0..*CodeableConceptHigh, low, normal, etc.
Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.


.... referenceRange 0..*See referenceRange (Observation)Provides guide for interpretation of component result

doco Documentation for this format

Terminology Bindings

PathConformanceValueSet / Code
Observation.languagepreferredCommonLanguages
Additional Bindings Purpose
AllLanguages Max Binding
Observation.statusrequiredObservationStatus
Observation.categorypreferredObservationCategoryCodes
Observation.codeexamplePattern: SNOMED CT code 712744002
Observation.value[x]requiredKLFollowUpCodes
Observation.dataAbsentReasonextensibleDataAbsentReason
Observation.interpretationextensibleObservationInterpretationCodes
Observation.bodySiteexampleSNOMEDCTBodyStructures
Observation.methodexampleObservationMethods
Observation.referenceRange.typepreferredObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesToexampleObservationReferenceRangeAppliesToCodes
Observation.component.codeexampleLOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReasonextensibleDataAbsentReason
Observation.component.interpretationextensibleObservationInterpretationCodes

 

Other representations of profile: CSV, Excel, Schematron