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.

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

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
status		1..1	code	[DK] opfølgningsresultatStatus
code		1..1	CodeableConcept	Type of observation (code / type) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
coding		0..*	Coding	[DK] opfølgningsresultatkode
subject		0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus		0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter		0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]		1..1	dateTime	[DK] opfølgningsresultatTid
performer		0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]		0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (required)
coding		0..*	Coding	[DK] struktureretOpfølgningsresultat
text		0..1	string	[DK] opfølgningsresultat
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.value[x]	required	KLFollowUpCodes

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsresultatStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
coding	Σ	0..*	Coding	[DK] opfølgningsresultatkode
subject	Σ	0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus	Σ	0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter	Σ	0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]	Σ	1..1	dateTime	[DK] opfølgningsresultatTid
performer	Σ	0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]	ΣC	0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (required)
coding	Σ	0..*	Coding	[DK] struktureretOpfølgningsresultat
text	Σ	0..1	string	[DK] opfølgningsresultat
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Observation.status	required	ObservationStatus
Observation.code	example	Pattern: SNOMED CT code 712744002
Observation.value[x]	required	KLFollowUpCodes

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	[DK] opfølgningsresultatStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
category		0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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] opfølgningsresultatkode
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus	Σ	0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter	Σ	0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]	Σ	1..1	dateTime	[DK] opfølgningsresultatTid
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]	ΣC	0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (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] struktureretOpfølgningsresultat
text	Σ	0..1	string	[DK] opfølgningsresultat
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation
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
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(Observation | QuestionnaireResponse | MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
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	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.code	example	Pattern: SNOMED CT code 712744002
Observation.value[x]	required	KLFollowUpCodes
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	example	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	example	LOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

Differential View

This structure is derived from Observation

Name	Flags	Card.	Type	Description & Constraints
Observation		0..*	Observation	Measurements and simple assertions
status		1..1	code	[DK] opfølgningsresultatStatus
code		1..1	CodeableConcept	Type of observation (code / type) Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
coding		0..*	Coding	[DK] opfølgningsresultatkode
subject		0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus		0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter		0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]		1..1	dateTime	[DK] opfølgningsresultatTid
performer		0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]		0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (required)
coding		0..*	Coding	[DK] struktureretOpfølgningsresultat
text		0..1	string	[DK] opfølgningsresultat
Documentation for this format

Terminology Bindings (Differential)

Path	Conformance	ValueSet
Observation.value[x]	required	KLFollowUpCodes

Key Elements View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
status	?!Σ	1..1	code	[DK] opfølgningsresultatStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
coding	Σ	0..*	Coding	[DK] opfølgningsresultatkode
subject	Σ	0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus	Σ	0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter	Σ	0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]	Σ	1..1	dateTime	[DK] opfølgningsresultatTid
performer	Σ	0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]	ΣC	0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (required)
coding	Σ	0..*	Coding	[DK] struktureretOpfølgningsresultat
text	Σ	0..1	string	[DK] opfølgningsresultat
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Observation.status	required	ObservationStatus
Observation.code	example	Pattern: SNOMED CT code 712744002
Observation.value[x]	required	KLFollowUpCodes

Snapshot View

Name	Flags	Card.	Type	Description & Constraints
Observation	C	0..*	Observation	Measurements and simple assertions
id	Σ	0..1	id	Logical id of this artifact
meta	Σ	0..1	Meta	Metadata about the resource
implicitRules	?!Σ	0..1	uri	A set of rules under which this content was created
language		0..1	code	Language of the resource content Binding: CommonLanguages (preferred): A human language. Additional Bindings Purpose AllLanguages Max Binding
text		0..1	Narrative	Text summary of the resource, for human interpretation
contained		0..*	Resource	Contained, inline Resources
extension		0..*	Extension	Additional content defined by implementations
modifierExtension	?!	0..*	Extension	Extensions that cannot be ignored
identifier	Σ	0..*	Identifier	Business Identifier for observation
basedOn	Σ	0..*	Reference(CarePlan | DeviceRequest | ImmunizationRecommendation | MedicationRequest | NutritionOrder | ServiceRequest)	Fulfills plan, proposal or order
partOf	Σ	0..*	Reference(MedicationAdministration | MedicationDispense | MedicationStatement | Procedure | Immunization | ImagingStudy)	Part of referenced event
status	?!Σ	1..1	code	[DK] opfølgningsresultatStatus Binding: ObservationStatus (required): Codes providing the status of an observation.
category		0..*	CodeableConcept	Classification of type of observation Binding: ObservationCategoryCodes (preferred): Codes for high level observation categories.
code	Σ	1..1	CodeableConcept	Type of observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations. Required Pattern: At least the following
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
coding		1..*	Coding	Code defined by a terminology system Fixed Value: (complex)
id		0..1	string	Unique id for inter-element referencing
extension		0..*	Extension	Additional content defined by implementations
system		1..1	uri	Identity of the terminology system Fixed Value: http://snomed.info/sct
version		0..1	string	Version of the system - if relevant
code		1..1	code	Symbol in syntax defined by the system Fixed Value: 712744002
display		0..1	string	Representation defined by the system
userSelected		0..1	boolean	If this coding was chosen directly by the user
text		0..1	string	Plain text representation of the concept
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] opfølgningsresultatkode
text	Σ	0..1	string	Plain text representation of the concept
subject	Σ	0..1	Reference(Citizen)	[DK] opfølgningsresultatSubjekt
focus	Σ	0..*	Reference(PlannedIntervention | Condition | CarePlan)	[DK] opfølgningsresultatFokus
encounter	Σ	0..1	Reference(Encounter)	[DK] opfølgningsresultatKontakt
effective[x]	Σ	1..1	dateTime	[DK] opfølgningsresultatTid
issued	Σ	0..1	instant	Date/Time this version was made available
performer	Σ	0..*	Reference(Practioner)	[DK] opfølgningsresultatAnsvarlig
value[x]	ΣC	0..1	CodeableConcept	Actual result Binding: KLOpfølgningKodes (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] struktureretOpfølgningsresultat
text	Σ	0..1	string	[DK] opfølgningsresultat
dataAbsentReason	C	0..1	CodeableConcept	Why the result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
note		0..*	Annotation	Comments about the observation
bodySite		0..1	CodeableConcept	Observed body part Binding: SNOMEDCTBodyStructures (example): Codes describing anatomical locations. May include laterality.
method		0..1	CodeableConcept	How it was done Binding: ObservationMethods (example): Methods for simple observations.
specimen		0..1	Reference(Specimen)	Specimen used for this observation
device		0..1	Reference(Device | DeviceMetric)	(Measurement) Device
referenceRange	C	0..*	BackboneElement	Provides guide for interpretation
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
low	C	0..1	SimpleQuantity	Low Range, if relevant
high	C	0..1	SimpleQuantity	High Range, if relevant
type		0..1	CodeableConcept	Reference range qualifier Binding: ObservationReferenceRangeMeaningCodes (preferred): Code for the meaning of a reference range.
appliesTo		0..*	CodeableConcept	Reference range population Binding: ObservationReferenceRangeAppliesToCodes (example): Codes identifying the population the reference range applies to.
age		0..1	Range	Applicable age range, if relevant
text		0..1	string	Text based reference range in an observation
hasMember	Σ	0..*	Reference(Observation | QuestionnaireResponse | MolecularSequence)	Related resource that belongs to the Observation group
derivedFrom	Σ	0..*	Reference(DocumentReference | ImagingStudy | Media | QuestionnaireResponse | Observation | MolecularSequence)	Related measurements the observation is made from
component	Σ	0..*	BackboneElement	Component results
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	Σ	1..1	CodeableConcept	Type of component observation (code / type) Binding: LOINCCodes (example): Codes identifying names of simple observations.
value[x]	Σ	0..1		Actual component result
valueQuantity			Quantity
valueCodeableConcept			CodeableConcept
valueString			string
valueBoolean			boolean
valueInteger			integer
valueRange			Range
valueRatio			Ratio
valueSampledData			SampledData
valueTime			time
valueDateTime			dateTime
valuePeriod			Period
dataAbsentReason	C	0..1	CodeableConcept	Why the component result is missing Binding: DataAbsentReason (extensible): Codes specifying why the result (Observation.value[x]) is missing.
interpretation		0..*	CodeableConcept	High, low, normal, etc. Binding: ObservationInterpretationCodes (extensible): Codes identifying interpretations of observations.
referenceRange		0..*	See referenceRange (Observation)	Provides guide for interpretation of component result
Documentation for this format

Terminology Bindings

Path	Conformance	ValueSet / Code
Observation.language	preferred	CommonLanguages Additional Bindings Purpose AllLanguages Max Binding
Observation.status	required	ObservationStatus
Observation.category	preferred	ObservationCategoryCodes
Observation.code	example	Pattern: SNOMED CT code 712744002
Observation.value[x]	required	KLFollowUpCodes
Observation.dataAbsentReason	extensible	DataAbsentReason
Observation.interpretation	extensible	ObservationInterpretationCodes
Observation.bodySite	example	SNOMEDCTBodyStructures
Observation.method	example	ObservationMethods
Observation.referenceRange.type	preferred	ObservationReferenceRangeMeaningCodes
Observation.referenceRange.appliesTo	example	ObservationReferenceRangeAppliesToCodes
Observation.component.code	example	LOINCCodes (a valid code from LOINC)
Observation.component.dataAbsentReason	extensible	DataAbsentReason
Observation.component.interpretation	extensible	ObservationInterpretationCodes

This structure is derived from Observation

Summary

Mandatory: 1 element

Structures

This structure refers to these other structures:

• Citizen (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCitizen)
• PlannedIntervention (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialPlannedIntervention)
• Condition (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialCondition)
• CarePlan (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialCarePlan)
• Encounter (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonCareSocialEncounter)
• Practioner (http://kl.dk/fhir/common/caresocial/StructureDefinition/KLCommonPractitioner)